hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|MA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
"Lifespan of Massachusetts – Taunton, DBA Morton Hospital",    2025-03-21,2.0.0,Morton Hospital,"88 Washington Street, Taunton MA 02780",22-0073,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,code|5,code|5|type,modifiers,setting,billing_class,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,standard_charge|min,standard_charge|max,additional_generic_notes,standard_charge|Aetna|Aetna|negotiated_dollar,standard_charge|Aetna|Aetna|negotiated_percentage,standard_charge|Aetna|Aetna|negotiated_algorithm,standard_charge|Aetna|Aetna|methodology,estimated_amount|Aetna|Aetna,additional_payer_notes|Aetna|Aetna,standard_charge|Aetna|Aetna Medicare Advantage|negotiated_dollar,standard_charge|Aetna|Aetna Medicare Advantage|negotiated_percentage,standard_charge|Aetna|Aetna Medicare Advantage|negotiated_algorithm,standard_charge|Aetna|Aetna Medicare Advantage|methodology,estimated_amount|Aetna|Aetna Medicare Advantage,additional_payer_notes|Aetna|Aetna Medicare Advantage,standard_charge|Assurant|Assurant|negotiated_dollar,standard_charge|Assurant|Assurant|negotiated_percentage,standard_charge|Assurant|Assurant|negotiated_algorithm,standard_charge|Assurant|Assurant|methodology,estimated_amount|Assurant|Assurant,additional_payer_notes|Assurant|Assurant,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS HMO Blue|negotiated_dollar,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS HMO Blue|negotiated_percentage,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS HMO Blue|negotiated_algorithm,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS HMO Blue|methodology,estimated_amount|Blue Cross and Blue Shield of Massachusetts|BCBS HMO Blue,additional_payer_notes|Blue Cross and Blue Shield of Massachusetts|BCBS HMO Blue,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS Indemnity|negotiated_dollar,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS Indemnity|negotiated_percentage,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS Indemnity|negotiated_algorithm,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS Indemnity|methodology,estimated_amount|Blue Cross and Blue Shield of Massachusetts|BCBS Indemnity,additional_payer_notes|Blue Cross and Blue Shield of Massachusetts|BCBS Indemnity,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS Medicare|negotiated_dollar,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS Medicare|negotiated_percentage,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS Medicare|negotiated_algorithm,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS Medicare|methodology,estimated_amount|Blue Cross and Blue Shield of Massachusetts|BCBS Medicare,additional_payer_notes|Blue Cross and Blue Shield of Massachusetts|BCBS Medicare,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS PPO|negotiated_dollar,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS PPO|negotiated_percentage,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS PPO|negotiated_algorithm,standard_charge|Blue Cross and Blue Shield of Massachusetts|BCBS PPO|methodology,estimated_amount|Blue Cross and Blue Shield of Massachusetts|BCBS PPO,additional_payer_notes|Blue Cross and Blue Shield of Massachusetts|BCBS PPO,standard_charge|Beacon Commercial|Beacon Commercial|negotiated_dollar,standard_charge|Beacon Commercial|Beacon Commercial|negotiated_percentage,standard_charge|Beacon Commercial|Beacon Commercial|negotiated_algorithm,standard_charge|Beacon Commercial|Beacon Commercial|methodology,estimated_amount|Beacon Commercial|Beacon Commercial,additional_payer_notes|Beacon Commercial|Beacon Commercial,standard_charge|Beacon Medicaid Managed|Beacon Medicaid Managed|negotiated_dollar,standard_charge|Beacon Medicaid Managed|Beacon Medicaid Managed|negotiated_percentage,standard_charge|Beacon Medicaid Managed|Beacon Medicaid Managed|negotiated_algorithm,standard_charge|Beacon Medicaid Managed|Beacon Medicaid Managed|methodology,estimated_amount|Beacon Medicaid Managed|Beacon Medicaid Managed,additional_payer_notes|Beacon Medicaid Managed|Beacon Medicaid Managed,standard_charge|Beacon Medicare Managed|Beacon Medicare Managed|negotiated_dollar,standard_charge|Beacon Medicare Managed|Beacon Medicare Managed|negotiated_percentage,standard_charge|Beacon Medicare Managed|Beacon Medicare Managed|negotiated_algorithm,standard_charge|Beacon Medicare Managed|Beacon Medicare Managed|methodology,estimated_amount|Beacon Medicare Managed|Beacon Medicare Managed,additional_payer_notes|Beacon Medicare Managed|Beacon Medicare Managed,standard_charge|Beacon|Beacon NHP|negotiated_dollar,standard_charge|Beacon|Beacon NHP|negotiated_percentage,standard_charge|Beacon|Beacon NHP|negotiated_algorithm,standard_charge|Beacon|Beacon NHP|methodology,estimated_amount|Beacon|Beacon NHP,additional_payer_notes|Beacon|Beacon NHP,standard_charge|Boston Medical Center Health Plan Inc|BMC Healthnet Well Sense|negotiated_dollar,standard_charge|Boston Medical Center Health Plan Inc|BMC Healthnet Well Sense|negotiated_percentage,standard_charge|Boston Medical Center Health Plan Inc|BMC Healthnet Well Sense|negotiated_algorithm,standard_charge|Boston Medical Center Health Plan Inc|BMC Healthnet Well Sense|methodology,estimated_amount|Boston Medical Center Health Plan Inc|BMC Healthnet Well Sense,additional_payer_notes|Boston Medical Center Health Plan Inc|BMC Healthnet Well Sense,standard_charge|BMC Hlthnet|BMC Hlthnet|negotiated_dollar,standard_charge|BMC Hlthnet|BMC Hlthnet|negotiated_percentage,standard_charge|BMC Hlthnet|BMC Hlthnet|negotiated_algorithm,standard_charge|BMC Hlthnet|BMC Hlthnet|methodology,estimated_amount|BMC Hlthnet|BMC Hlthnet,additional_payer_notes|BMC Hlthnet|BMC Hlthnet,standard_charge|BMC Hlthnet Medicaid|BMC Hlthnet Medicaid|negotiated_dollar,standard_charge|BMC Hlthnet Medicaid|BMC Hlthnet Medicaid|negotiated_percentage,standard_charge|BMC Hlthnet Medicaid|BMC Hlthnet Medicaid|negotiated_algorithm,standard_charge|BMC Hlthnet Medicaid|BMC Hlthnet Medicaid|methodology,estimated_amount|BMC Hlthnet Medicaid|BMC Hlthnet Medicaid,additional_payer_notes|BMC Hlthnet Medicaid|BMC Hlthnet Medicaid,standard_charge|BMC Hlthnet|BMC Hlthnet-Silver|negotiated_dollar,standard_charge|BMC Hlthnet|BMC Hlthnet-Silver|negotiated_percentage,standard_charge|BMC Hlthnet|BMC Hlthnet-Silver|negotiated_algorithm,standard_charge|BMC Hlthnet|BMC Hlthnet-Silver|methodology,estimated_amount|BMC Hlthnet|BMC Hlthnet-Silver,additional_payer_notes|BMC Hlthnet|BMC Hlthnet-Silver,standard_charge|BMC WellSense Senior Care Options|BMC WellSense Senior Care Options|negotiated_dollar,standard_charge|BMC WellSense Senior Care Options|BMC WellSense Senior Care Options|negotiated_percentage,standard_charge|BMC WellSense Senior Care Options|BMC WellSense Senior Care Options|negotiated_algorithm,standard_charge|BMC WellSense Senior Care Options|BMC WellSense Senior Care Options|methodology,estimated_amount|BMC WellSense Senior Care Options|BMC WellSense Senior Care Options,additional_payer_notes|BMC WellSense Senior Care Options|BMC WellSense Senior Care Options,standard_charge|CeltiCare|CeltiCare CHIP|negotiated_dollar,standard_charge|CeltiCare|CeltiCare CHIP|negotiated_percentage,standard_charge|CeltiCare|CeltiCare CHIP|negotiated_algorithm,standard_charge|CeltiCare|CeltiCare CHIP|methodology,estimated_amount|CeltiCare|CeltiCare CHIP,additional_payer_notes|CeltiCare|CeltiCare CHIP,standard_charge|CeltiCare|CeltiCare Choice|negotiated_dollar,standard_charge|CeltiCare|CeltiCare Choice|negotiated_percentage,standard_charge|CeltiCare|CeltiCare Choice|negotiated_algorithm,standard_charge|CeltiCare|CeltiCare Choice|methodology,estimated_amount|CeltiCare|CeltiCare Choice,additional_payer_notes|CeltiCare|CeltiCare Choice,standard_charge|CeltiCare Health Plan of Massachusetts|CeltiCare Medicaid CarePlus|negotiated_dollar,standard_charge|CeltiCare Health Plan of Massachusetts|CeltiCare Medicaid CarePlus|negotiated_percentage,standard_charge|CeltiCare Health Plan of Massachusetts|CeltiCare Medicaid CarePlus|negotiated_algorithm,standard_charge|CeltiCare Health Plan of Massachusetts|CeltiCare Medicaid CarePlus|methodology,estimated_amount|CeltiCare Health Plan of Massachusetts|CeltiCare Medicaid CarePlus,additional_payer_notes|CeltiCare Health Plan of Massachusetts|CeltiCare Medicaid CarePlus,standard_charge|CIGNA Healthcare|CIGNA Healthcare|negotiated_dollar,standard_charge|CIGNA Healthcare|CIGNA Healthcare|negotiated_percentage,standard_charge|CIGNA Healthcare|CIGNA Healthcare|negotiated_algorithm,standard_charge|CIGNA Healthcare|CIGNA Healthcare|methodology,estimated_amount|CIGNA Healthcare|CIGNA Healthcare,additional_payer_notes|CIGNA Healthcare|CIGNA Healthcare,standard_charge|CIGNA Healthcare|CIGNA Medicare|negotiated_dollar,standard_charge|CIGNA Healthcare|CIGNA Medicare|negotiated_percentage,standard_charge|CIGNA Healthcare|CIGNA Medicare|negotiated_algorithm,standard_charge|CIGNA Healthcare|CIGNA Medicare|methodology,estimated_amount|CIGNA Healthcare|CIGNA Medicare,additional_payer_notes|CIGNA Healthcare|CIGNA Medicare,standard_charge|Commercial Non-Contracted|Commercial Non-Contracted|negotiated_dollar,standard_charge|Commercial Non-Contracted|Commercial Non-Contracted|negotiated_percentage,standard_charge|Commercial Non-Contracted|Commercial Non-Contracted|negotiated_algorithm,standard_charge|Commercial Non-Contracted|Commercial Non-Contracted|methodology,estimated_amount|Commercial Non-Contracted|Commercial Non-Contracted,additional_payer_notes|Commercial Non-Contracted|Commercial Non-Contracted,standard_charge|Commercial|COMMERCIAL-HISTORICAL PAF|negotiated_dollar,standard_charge|Commercial|COMMERCIAL-HISTORICAL PAF|negotiated_percentage,standard_charge|Commercial|COMMERCIAL-HISTORICAL PAF|negotiated_algorithm,standard_charge|Commercial|COMMERCIAL-HISTORICAL PAF|methodology,estimated_amount|Commercial|COMMERCIAL-HISTORICAL PAF,additional_payer_notes|Commercial|COMMERCIAL-HISTORICAL PAF,standard_charge|Commonwealth Care Alliance|Commonwealth Care Alliance|negotiated_dollar,standard_charge|Commonwealth Care Alliance|Commonwealth Care Alliance|negotiated_percentage,standard_charge|Commonwealth Care Alliance|Commonwealth Care Alliance|negotiated_algorithm,standard_charge|Commonwealth Care Alliance|Commonwealth Care Alliance|methodology,estimated_amount|Commonwealth Care Alliance|Commonwealth Care Alliance,additional_payer_notes|Commonwealth Care Alliance|Commonwealth Care Alliance,standard_charge|Commonwealth Care Alliance-PPO|Commonwealth Care Alliance-PPO|negotiated_dollar,standard_charge|Commonwealth Care Alliance-PPO|Commonwealth Care Alliance-PPO|negotiated_percentage,standard_charge|Commonwealth Care Alliance-PPO|Commonwealth Care Alliance-PPO|negotiated_algorithm,standard_charge|Commonwealth Care Alliance-PPO|Commonwealth Care Alliance-PPO|methodology,estimated_amount|Commonwealth Care Alliance-PPO|Commonwealth Care Alliance-PPO,additional_payer_notes|Commonwealth Care Alliance-PPO|Commonwealth Care Alliance-PPO,standard_charge|COVID19 HRSA|COVID19 HRSA UNINSURED|negotiated_dollar,standard_charge|COVID19 HRSA|COVID19 HRSA UNINSURED|negotiated_percentage,standard_charge|COVID19 HRSA|COVID19 HRSA UNINSURED|negotiated_algorithm,standard_charge|COVID19 HRSA|COVID19 HRSA UNINSURED|methodology,estimated_amount|COVID19 HRSA|COVID19 HRSA UNINSURED,additional_payer_notes|COVID19 HRSA|COVID19 HRSA UNINSURED,standard_charge|Elder Services|Elder Services|negotiated_dollar,standard_charge|Elder Services|Elder Services|negotiated_percentage,standard_charge|Elder Services|Elder Services|negotiated_algorithm,standard_charge|Elder Services|Elder Services|methodology,estimated_amount|Elder Services|Elder Services,additional_payer_notes|Elder Services|Elder Services,standard_charge|Employer Direct Healthcare|Employer Direct Healthcare|negotiated_dollar,standard_charge|Employer Direct Healthcare|Employer Direct Healthcare|negotiated_percentage,standard_charge|Employer Direct Healthcare|Employer Direct Healthcare|negotiated_algorithm,standard_charge|Employer Direct Healthcare|Employer Direct Healthcare|methodology,estimated_amount|Employer Direct Healthcare|Employer Direct Healthcare,additional_payer_notes|Employer Direct Healthcare|Employer Direct Healthcare,standard_charge|Eternal Health Medicare Advantage|Eternal Health Medicare Advantage|negotiated_dollar,standard_charge|Eternal Health Medicare Advantage|Eternal Health Medicare Advantage|negotiated_percentage,standard_charge|Eternal Health Medicare Advantage|Eternal Health Medicare Advantage|negotiated_algorithm,standard_charge|Eternal Health Medicare Advantage|Eternal Health Medicare Advantage|methodology,estimated_amount|Eternal Health Medicare Advantage|Eternal Health Medicare Advantage,additional_payer_notes|Eternal Health Medicare Advantage|Eternal Health Medicare Advantage,standard_charge|Fallon Community Health Plan|Fallon|negotiated_dollar,standard_charge|Fallon Community Health Plan|Fallon|negotiated_percentage,standard_charge|Fallon Community Health Plan|Fallon|negotiated_algorithm,standard_charge|Fallon Community Health Plan|Fallon|methodology,estimated_amount|Fallon Community Health Plan|Fallon,additional_payer_notes|Fallon Community Health Plan|Fallon,standard_charge|Fallon Health Plan|Fallon Medicaid Managed Care|negotiated_dollar,standard_charge|Fallon Health Plan|Fallon Medicaid Managed Care|negotiated_percentage,standard_charge|Fallon Health Plan|Fallon Medicaid Managed Care|negotiated_algorithm,standard_charge|Fallon Health Plan|Fallon Medicaid Managed Care|methodology,estimated_amount|Fallon Health Plan|Fallon Medicaid Managed Care,additional_payer_notes|Fallon Health Plan|Fallon Medicaid Managed Care,standard_charge|Fallon Health Plan|Fallon Medicare Managed Care|negotiated_dollar,standard_charge|Fallon Health Plan|Fallon Medicare Managed Care|negotiated_percentage,standard_charge|Fallon Health Plan|Fallon Medicare Managed Care|negotiated_algorithm,standard_charge|Fallon Health Plan|Fallon Medicare Managed Care|methodology,estimated_amount|Fallon Health Plan|Fallon Medicare Managed Care,additional_payer_notes|Fallon Health Plan|Fallon Medicare Managed Care,standard_charge|Harvard Pilgrim Health Care|Harvard Pilgrim Managed Care|negotiated_dollar,standard_charge|Harvard Pilgrim Health Care|Harvard Pilgrim Managed Care|negotiated_percentage,standard_charge|Harvard Pilgrim Health Care|Harvard Pilgrim Managed Care|negotiated_algorithm,standard_charge|Harvard Pilgrim Health Care|Harvard Pilgrim Managed Care|methodology,estimated_amount|Harvard Pilgrim Health Care|Harvard Pilgrim Managed Care,additional_payer_notes|Harvard Pilgrim Health Care|Harvard Pilgrim Managed Care,standard_charge|Harvard Pilgrim Health Care|Harvard Pilgrim Managed Care-Self Insured|negotiated_dollar,standard_charge|Harvard Pilgrim Health Care|Harvard Pilgrim Managed Care-Self Insured|negotiated_percentage,standard_charge|Harvard Pilgrim Health Care|Harvard Pilgrim Managed Care-Self Insured|negotiated_algorithm,standard_charge|Harvard Pilgrim Health Care|Harvard Pilgrim Managed Care-Self Insured|methodology,estimated_amount|Harvard Pilgrim Health Care|Harvard Pilgrim Managed Care-Self Insured,additional_payer_notes|Harvard Pilgrim Health Care|Harvard Pilgrim Managed Care-Self Insured,standard_charge|Harvard Pilgrim Health Care|Harvard Pilgrim Medicare Managed Care|negotiated_dollar,standard_charge|Harvard Pilgrim Health Care|Harvard Pilgrim Medicare Managed Care|negotiated_percentage,standard_charge|Harvard Pilgrim Health Care|Harvard Pilgrim Medicare Managed Care|negotiated_algorithm,standard_charge|Harvard Pilgrim Health Care|Harvard Pilgrim Medicare Managed Care|methodology,estimated_amount|Harvard Pilgrim Health Care|Harvard Pilgrim Medicare Managed Care,additional_payer_notes|Harvard Pilgrim Health Care|Harvard Pilgrim Medicare Managed Care,standard_charge|Health Safety Net|Health Safety Net (HSN)|negotiated_dollar,standard_charge|Health Safety Net|Health Safety Net (HSN)|negotiated_percentage,standard_charge|Health Safety Net|Health Safety Net (HSN)|negotiated_algorithm,standard_charge|Health Safety Net|Health Safety Net (HSN)|methodology,estimated_amount|Health Safety Net|Health Safety Net (HSN),additional_payer_notes|Health Safety Net|Health Safety Net (HSN),standard_charge|Health Safety Net|HSN-ER Bad Debt|negotiated_dollar,standard_charge|Health Safety Net|HSN-ER Bad Debt|negotiated_percentage,standard_charge|Health Safety Net|HSN-ER Bad Debt|negotiated_algorithm,standard_charge|Health Safety Net|HSN-ER Bad Debt|methodology,estimated_amount|Health Safety Net|HSN-ER Bad Debt,additional_payer_notes|Health Safety Net|HSN-ER Bad Debt,standard_charge|Humana|Humana Medicare|negotiated_dollar,standard_charge|Humana|Humana Medicare|negotiated_percentage,standard_charge|Humana|Humana Medicare|negotiated_algorithm,standard_charge|Humana|Humana Medicare|methodology,estimated_amount|Humana|Humana Medicare,additional_payer_notes|Humana|Humana Medicare,standard_charge|Longevity Health Plan Medicare Advantage|Longevity Health Plan Medicare Advantage|negotiated_dollar,standard_charge|Longevity Health Plan Medicare Advantage|Longevity Health Plan Medicare Advantage|negotiated_percentage,standard_charge|Longevity Health Plan Medicare Advantage|Longevity Health Plan Medicare Advantage|negotiated_algorithm,standard_charge|Longevity Health Plan Medicare Advantage|Longevity Health Plan Medicare Advantage|methodology,estimated_amount|Longevity Health Plan Medicare Advantage|Longevity Health Plan Medicare Advantage,additional_payer_notes|Longevity Health Plan Medicare Advantage|Longevity Health Plan Medicare Advantage,standard_charge|Correct Care Solutions LLC|Mass DOC - Correct Care|negotiated_dollar,standard_charge|Correct Care Solutions LLC|Mass DOC - Correct Care|negotiated_percentage,standard_charge|Correct Care Solutions LLC|Mass DOC - Correct Care|negotiated_algorithm,standard_charge|Correct Care Solutions LLC|Mass DOC - Correct Care|methodology,estimated_amount|Correct Care Solutions LLC|Mass DOC - Correct Care,additional_payer_notes|Correct Care Solutions LLC|Mass DOC - Correct Care,standard_charge|Massachusetts Rehabilitation Commission|Mass Rehab|negotiated_dollar,standard_charge|Massachusetts Rehabilitation Commission|Mass Rehab|negotiated_percentage,standard_charge|Massachusetts Rehabilitation Commission|Mass Rehab|negotiated_algorithm,standard_charge|Massachusetts Rehabilitation Commission|Mass Rehab|methodology,estimated_amount|Massachusetts Rehabilitation Commission|Mass Rehab,additional_payer_notes|Massachusetts Rehabilitation Commission|Mass Rehab,standard_charge|MBHP|MBHP|negotiated_dollar,standard_charge|MBHP|MBHP|negotiated_percentage,standard_charge|MBHP|MBHP|negotiated_algorithm,standard_charge|MBHP|MBHP|methodology,estimated_amount|MBHP|MBHP,additional_payer_notes|MBHP|MBHP,standard_charge|MBHP|MBHP Steward ACO|negotiated_dollar,standard_charge|MBHP|MBHP Steward ACO|negotiated_percentage,standard_charge|MBHP|MBHP Steward ACO|negotiated_algorithm,standard_charge|MBHP|MBHP Steward ACO|methodology,estimated_amount|MBHP|MBHP Steward ACO,additional_payer_notes|MBHP|MBHP Steward ACO,standard_charge|Medicaid|Medicaid|negotiated_dollar,standard_charge|Medicaid|Medicaid|negotiated_percentage,standard_charge|Medicaid|Medicaid|negotiated_algorithm,standard_charge|Medicaid|Medicaid|methodology,estimated_amount|Medicaid|Medicaid,additional_payer_notes|Medicaid|Medicaid,standard_charge|Medicaid Managed - Miscellaneous|Medicaid Managed - Miscellaneous|negotiated_dollar,standard_charge|Medicaid Managed - Miscellaneous|Medicaid Managed - Miscellaneous|negotiated_percentage,standard_charge|Medicaid Managed - Miscellaneous|Medicaid Managed - Miscellaneous|negotiated_algorithm,standard_charge|Medicaid Managed - Miscellaneous|Medicaid Managed - Miscellaneous|methodology,estimated_amount|Medicaid Managed - Miscellaneous|Medicaid Managed - Miscellaneous,additional_payer_notes|Medicaid Managed - Miscellaneous|Medicaid Managed - Miscellaneous,standard_charge|Medicaid|Medicaid Out of State|negotiated_dollar,standard_charge|Medicaid|Medicaid Out of State|negotiated_percentage,standard_charge|Medicaid|Medicaid Out of State|negotiated_algorithm,standard_charge|Medicaid|Medicaid Out of State|methodology,estimated_amount|Medicaid|Medicaid Out of State,additional_payer_notes|Medicaid|Medicaid Out of State,standard_charge|Medicare|Medicare|negotiated_dollar,standard_charge|Medicare|Medicare|negotiated_percentage,standard_charge|Medicare|Medicare|negotiated_algorithm,standard_charge|Medicare|Medicare|methodology,estimated_amount|Medicare|Medicare,additional_payer_notes|Medicare|Medicare,standard_charge|Medicare Managed Miscellaneous|Medicare Managed Miscellaneous|negotiated_dollar,standard_charge|Medicare Managed Miscellaneous|Medicare Managed Miscellaneous|negotiated_percentage,standard_charge|Medicare Managed Miscellaneous|Medicare Managed Miscellaneous|negotiated_algorithm,standard_charge|Medicare Managed Miscellaneous|Medicare Managed Miscellaneous|methodology,estimated_amount|Medicare Managed Miscellaneous|Medicare Managed Miscellaneous,additional_payer_notes|Medicare Managed Miscellaneous|Medicare Managed Miscellaneous,standard_charge|Multiplan-PHCS|Multiplan-PHCS|negotiated_dollar,standard_charge|Multiplan-PHCS|Multiplan-PHCS|negotiated_percentage,standard_charge|Multiplan-PHCS|Multiplan-PHCS|negotiated_algorithm,standard_charge|Multiplan-PHCS|Multiplan-PHCS|methodology,estimated_amount|Multiplan-PHCS|Multiplan-PHCS,additional_payer_notes|Multiplan-PHCS|Multiplan-PHCS,standard_charge|Neighborhood Health Plan|Neighborhood Health CHIP|negotiated_dollar,standard_charge|Neighborhood Health Plan|Neighborhood Health CHIP|negotiated_percentage,standard_charge|Neighborhood Health Plan|Neighborhood Health CHIP|negotiated_algorithm,standard_charge|Neighborhood Health Plan|Neighborhood Health CHIP|methodology,estimated_amount|Neighborhood Health Plan|Neighborhood Health CHIP,additional_payer_notes|Neighborhood Health Plan|Neighborhood Health CHIP,standard_charge|Neighborhood Health HMO|Neighborhood Health HMO|negotiated_dollar,standard_charge|Neighborhood Health HMO|Neighborhood Health HMO|negotiated_percentage,standard_charge|Neighborhood Health HMO|Neighborhood Health HMO|negotiated_algorithm,standard_charge|Neighborhood Health HMO|Neighborhood Health HMO|methodology,estimated_amount|Neighborhood Health HMO|Neighborhood Health HMO,additional_payer_notes|Neighborhood Health HMO|Neighborhood Health HMO,standard_charge|Neighborhood Health Plan|Neighborhood Health Medicaid|negotiated_dollar,standard_charge|Neighborhood Health Plan|Neighborhood Health Medicaid|negotiated_percentage,standard_charge|Neighborhood Health Plan|Neighborhood Health Medicaid|negotiated_algorithm,standard_charge|Neighborhood Health Plan|Neighborhood Health Medicaid|methodology,estimated_amount|Neighborhood Health Plan|Neighborhood Health Medicaid,additional_payer_notes|Neighborhood Health Plan|Neighborhood Health Medicaid,standard_charge|Neighborhood Health Medicare Advantage|Neighborhood Health Medicare Advantage|negotiated_dollar,standard_charge|Neighborhood Health Medicare Advantage|Neighborhood Health Medicare Advantage|negotiated_percentage,standard_charge|Neighborhood Health Medicare Advantage|Neighborhood Health Medicare Advantage|negotiated_algorithm,standard_charge|Neighborhood Health Medicare Advantage|Neighborhood Health Medicare Advantage|methodology,estimated_amount|Neighborhood Health Medicare Advantage|Neighborhood Health Medicare Advantage,additional_payer_notes|Neighborhood Health Medicare Advantage|Neighborhood Health Medicare Advantage,standard_charge|Neighborhood Health RI|Neighborhood Health RI|negotiated_dollar,standard_charge|Neighborhood Health RI|Neighborhood Health RI|negotiated_percentage,standard_charge|Neighborhood Health RI|Neighborhood Health RI|negotiated_algorithm,standard_charge|Neighborhood Health RI|Neighborhood Health RI|methodology,estimated_amount|Neighborhood Health RI|Neighborhood Health RI,additional_payer_notes|Neighborhood Health RI|Neighborhood Health RI,standard_charge|Network Health|Network Health CHIP|negotiated_dollar,standard_charge|Network Health|Network Health CHIP|negotiated_percentage,standard_charge|Network Health|Network Health CHIP|negotiated_algorithm,standard_charge|Network Health|Network Health CHIP|methodology,estimated_amount|Network Health|Network Health CHIP,additional_payer_notes|Network Health|Network Health CHIP,standard_charge|Network Health - Tufts Health Public Plans|Network Health Medicaid|negotiated_dollar,standard_charge|Network Health - Tufts Health Public Plans|Network Health Medicaid|negotiated_percentage,standard_charge|Network Health - Tufts Health Public Plans|Network Health Medicaid|negotiated_algorithm,standard_charge|Network Health - Tufts Health Public Plans|Network Health Medicaid|methodology,estimated_amount|Network Health - Tufts Health Public Plans|Network Health Medicaid,additional_payer_notes|Network Health - Tufts Health Public Plans|Network Health Medicaid,standard_charge|Network Health-Tufts Health Public Plans|Network Health QHP Non-Subsidized|negotiated_dollar,standard_charge|Network Health-Tufts Health Public Plans|Network Health QHP Non-Subsidized|negotiated_percentage,standard_charge|Network Health-Tufts Health Public Plans|Network Health QHP Non-Subsidized|negotiated_algorithm,standard_charge|Network Health-Tufts Health Public Plans|Network Health QHP Non-Subsidized|methodology,estimated_amount|Network Health-Tufts Health Public Plans|Network Health QHP Non-Subsidized,additional_payer_notes|Network Health-Tufts Health Public Plans|Network Health QHP Non-Subsidized,standard_charge|Network Health-Tufts Health Public Plans|Network Health QHP Subsidized|negotiated_dollar,standard_charge|Network Health-Tufts Health Public Plans|Network Health QHP Subsidized|negotiated_percentage,standard_charge|Network Health-Tufts Health Public Plans|Network Health QHP Subsidized|negotiated_algorithm,standard_charge|Network Health-Tufts Health Public Plans|Network Health QHP Subsidized|methodology,estimated_amount|Network Health-Tufts Health Public Plans|Network Health QHP Subsidized,additional_payer_notes|Network Health-Tufts Health Public Plans|Network Health QHP Subsidized,standard_charge|nThrive|SELF PAY ELECTIVE|negotiated_dollar,standard_charge|nThrive|SELF PAY ELECTIVE|negotiated_percentage,standard_charge|nThrive|SELF PAY ELECTIVE|negotiated_algorithm,standard_charge|nThrive|SELF PAY ELECTIVE|methodology,estimated_amount|nThrive|SELF PAY ELECTIVE,additional_payer_notes|nThrive|SELF PAY ELECTIVE,standard_charge||SELF PAY EMERGENT|negotiated_dollar,standard_charge||SELF PAY EMERGENT|negotiated_percentage,standard_charge||SELF PAY EMERGENT|negotiated_algorithm,standard_charge||SELF PAY EMERGENT|methodology,estimated_amount||SELF PAY EMERGENT,additional_payer_notes||SELF PAY EMERGENT,standard_charge|Self Pay Non-Traditional|Self Pay Non-Traditional|negotiated_dollar,standard_charge|Self Pay Non-Traditional|Self Pay Non-Traditional|negotiated_percentage,standard_charge|Self Pay Non-Traditional|Self Pay Non-Traditional|negotiated_algorithm,standard_charge|Self Pay Non-Traditional|Self Pay Non-Traditional|methodology,estimated_amount|Self Pay Non-Traditional|Self Pay Non-Traditional,additional_payer_notes|Self Pay Non-Traditional|Self Pay Non-Traditional,standard_charge|Self-Pay|Self-Pay|negotiated_dollar,standard_charge|Self-Pay|Self-Pay|negotiated_percentage,standard_charge|Self-Pay|Self-Pay|negotiated_algorithm,standard_charge|Self-Pay|Self-Pay|methodology,estimated_amount|Self-Pay|Self-Pay,additional_payer_notes|Self-Pay|Self-Pay,standard_charge|Self-Pay Other|Self-Pay Other|negotiated_dollar,standard_charge|Self-Pay Other|Self-Pay Other|negotiated_percentage,standard_charge|Self-Pay Other|Self-Pay Other|negotiated_algorithm,standard_charge|Self-Pay Other|Self-Pay Other|methodology,estimated_amount|Self-Pay Other|Self-Pay Other,additional_payer_notes|Self-Pay Other|Self-Pay Other,standard_charge||Self-Pay Other Facility|negotiated_dollar,standard_charge||Self-Pay Other Facility|negotiated_percentage,standard_charge||Self-Pay Other Facility|negotiated_algorithm,standard_charge||Self-Pay Other Facility|methodology,estimated_amount||Self-Pay Other Facility,additional_payer_notes||Self-Pay Other Facility,standard_charge|Senior Whole Health|Senior Whole Health|negotiated_dollar,standard_charge|Senior Whole Health|Senior Whole Health|negotiated_percentage,standard_charge|Senior Whole Health|Senior Whole Health|negotiated_algorithm,standard_charge|Senior Whole Health|Senior Whole Health|methodology,estimated_amount|Senior Whole Health|Senior Whole Health,additional_payer_notes|Senior Whole Health|Senior Whole Health,standard_charge|Senior Whole Health-Behavioral Health|Senior Whole Health-Behavioral Health|negotiated_dollar,standard_charge|Senior Whole Health-Behavioral Health|Senior Whole Health-Behavioral Health|negotiated_percentage,standard_charge|Senior Whole Health-Behavioral Health|Senior Whole Health-Behavioral Health|negotiated_algorithm,standard_charge|Senior Whole Health-Behavioral Health|Senior Whole Health-Behavioral Health|methodology,estimated_amount|Senior Whole Health-Behavioral Health|Senior Whole Health-Behavioral Health,additional_payer_notes|Senior Whole Health-Behavioral Health|Senior Whole Health-Behavioral Health,standard_charge|Single Case Agreement|Single Case Agreement|negotiated_dollar,standard_charge|Single Case Agreement|Single Case Agreement|negotiated_percentage,standard_charge|Single Case Agreement|Single Case Agreement|negotiated_algorithm,standard_charge|Single Case Agreement|Single Case Agreement|methodology,estimated_amount|Single Case Agreement|Single Case Agreement,additional_payer_notes|Single Case Agreement|Single Case Agreement,standard_charge|Tufts Health Plan|THPP Medicare Managed Care|negotiated_dollar,standard_charge|Tufts Health Plan|THPP Medicare Managed Care|negotiated_percentage,standard_charge|Tufts Health Plan|THPP Medicare Managed Care|negotiated_algorithm,standard_charge|Tufts Health Plan|THPP Medicare Managed Care|methodology,estimated_amount|Tufts Health Plan|THPP Medicare Managed Care,additional_payer_notes|Tufts Health Plan|THPP Medicare Managed Care,standard_charge|Tricare|Tricare|negotiated_dollar,standard_charge|Tricare|Tricare|negotiated_percentage,standard_charge|Tricare|Tricare|negotiated_algorithm,standard_charge|Tricare|Tricare|methodology,estimated_amount|Tricare|Tricare,additional_payer_notes|Tricare|Tricare,standard_charge|Tufts|Tufts HMO|negotiated_dollar,standard_charge|Tufts|Tufts HMO|negotiated_percentage,standard_charge|Tufts|Tufts HMO|negotiated_algorithm,standard_charge|Tufts|Tufts HMO|methodology,estimated_amount|Tufts|Tufts HMO,additional_payer_notes|Tufts|Tufts HMO,standard_charge|Tufts Health Plan|Tufts Medicare Managed Care|negotiated_dollar,standard_charge|Tufts Health Plan|Tufts Medicare Managed Care|negotiated_percentage,standard_charge|Tufts Health Plan|Tufts Medicare Managed Care|negotiated_algorithm,standard_charge|Tufts Health Plan|Tufts Medicare Managed Care|methodology,estimated_amount|Tufts Health Plan|Tufts Medicare Managed Care,additional_payer_notes|Tufts Health Plan|Tufts Medicare Managed Care,standard_charge|Tufts Medicare Managed Care-Steward PCP|Tufts Medicare Managed Care-Steward PCP|negotiated_dollar,standard_charge|Tufts Medicare Managed Care-Steward PCP|Tufts Medicare Managed Care-Steward PCP|negotiated_percentage,standard_charge|Tufts Medicare Managed Care-Steward PCP|Tufts Medicare Managed Care-Steward PCP|negotiated_algorithm,standard_charge|Tufts Medicare Managed Care-Steward PCP|Tufts Medicare Managed Care-Steward PCP|methodology,estimated_amount|Tufts Medicare Managed Care-Steward PCP|Tufts Medicare Managed Care-Steward PCP,additional_payer_notes|Tufts Medicare Managed Care-Steward PCP|Tufts Medicare Managed Care-Steward PCP,standard_charge|Tufts|Tufts Plan Spirit|negotiated_dollar,standard_charge|Tufts|Tufts Plan Spirit|negotiated_percentage,standard_charge|Tufts|Tufts Plan Spirit|negotiated_algorithm,standard_charge|Tufts|Tufts Plan Spirit|methodology,estimated_amount|Tufts|Tufts Plan Spirit,additional_payer_notes|Tufts|Tufts Plan Spirit,standard_charge|Tufts|Tufts PPO|negotiated_dollar,standard_charge|Tufts|Tufts PPO|negotiated_percentage,standard_charge|Tufts|Tufts PPO|negotiated_algorithm,standard_charge|Tufts|Tufts PPO|methodology,estimated_amount|Tufts|Tufts PPO,additional_payer_notes|Tufts|Tufts PPO,standard_charge|Tufts|Tufts Select|negotiated_dollar,standard_charge|Tufts|Tufts Select|negotiated_percentage,standard_charge|Tufts|Tufts Select|negotiated_algorithm,standard_charge|Tufts|Tufts Select|methodology,estimated_amount|Tufts|Tufts Select,additional_payer_notes|Tufts|Tufts Select,standard_charge|Unicare|Unicare|negotiated_dollar,standard_charge|Unicare|Unicare|negotiated_percentage,standard_charge|Unicare|Unicare|negotiated_algorithm,standard_charge|Unicare|Unicare|methodology,estimated_amount|Unicare|Unicare,additional_payer_notes|Unicare|Unicare,standard_charge|United Behavioral Health|United Behavioral Health Commercial|negotiated_dollar,standard_charge|United Behavioral Health|United Behavioral Health Commercial|negotiated_percentage,standard_charge|United Behavioral Health|United Behavioral Health Commercial|negotiated_algorithm,standard_charge|United Behavioral Health|United Behavioral Health Commercial|methodology,estimated_amount|United Behavioral Health|United Behavioral Health Commercial,additional_payer_notes|United Behavioral Health|United Behavioral Health Commercial,standard_charge|United Behavioral Health|United Behavioral Health Medicaid|negotiated_dollar,standard_charge|United Behavioral Health|United Behavioral Health Medicaid|negotiated_percentage,standard_charge|United Behavioral Health|United Behavioral Health Medicaid|negotiated_algorithm,standard_charge|United Behavioral Health|United Behavioral Health Medicaid|methodology,estimated_amount|United Behavioral Health|United Behavioral Health Medicaid,additional_payer_notes|United Behavioral Health|United Behavioral Health Medicaid,standard_charge|United|United Behavioral Health Medicare|negotiated_dollar,standard_charge|United|United Behavioral Health Medicare|negotiated_percentage,standard_charge|United|United Behavioral Health Medicare|negotiated_algorithm,standard_charge|United|United Behavioral Health Medicare|methodology,estimated_amount|United|United Behavioral Health Medicare,additional_payer_notes|United|United Behavioral Health Medicare,standard_charge|United Health Care|United Health Care|negotiated_dollar,standard_charge|United Health Care|United Health Care|negotiated_percentage,standard_charge|United Health Care|United Health Care|negotiated_algorithm,standard_charge|United Health Care|United Health Care|methodology,estimated_amount|United Health Care|United Health Care,additional_payer_notes|United Health Care|United Health Care,standard_charge|United Healthcare Insurance Company|United Health Evercare|negotiated_dollar,standard_charge|United Healthcare Insurance Company|United Health Evercare|negotiated_percentage,standard_charge|United Healthcare Insurance Company|United Health Evercare|negotiated_algorithm,standard_charge|United Healthcare Insurance Company|United Health Evercare|methodology,estimated_amount|United Healthcare Insurance Company|United Health Evercare,additional_payer_notes|United Healthcare Insurance Company|United Health Evercare,standard_charge|United Medicare Advantage|United Medicare Advantage|negotiated_dollar,standard_charge|United Medicare Advantage|United Medicare Advantage|negotiated_percentage,standard_charge|United Medicare Advantage|United Medicare Advantage|negotiated_algorithm,standard_charge|United Medicare Advantage|United Medicare Advantage|methodology,estimated_amount|United Medicare Advantage|United Medicare Advantage,additional_payer_notes|United Medicare Advantage|United Medicare Advantage,standard_charge|United Medicare SCO/OneCare|United Medicare SCO/OneCare|negotiated_dollar,standard_charge|United Medicare SCO/OneCare|United Medicare SCO/OneCare|negotiated_percentage,standard_charge|United Medicare SCO/OneCare|United Medicare SCO/OneCare|negotiated_algorithm,standard_charge|United Medicare SCO/OneCare|United Medicare SCO/OneCare|methodology,estimated_amount|United Medicare SCO/OneCare|United Medicare SCO/OneCare,additional_payer_notes|United Medicare SCO/OneCare|United Medicare SCO/OneCare,standard_charge|US Family Health Plan|US Family Health Plan|negotiated_dollar,standard_charge|US Family Health Plan|US Family Health Plan|negotiated_percentage,standard_charge|US Family Health Plan|US Family Health Plan|negotiated_algorithm,standard_charge|US Family Health Plan|US Family Health Plan|methodology,estimated_amount|US Family Health Plan|US Family Health Plan,additional_payer_notes|US Family Health Plan|US Family Health Plan,standard_charge|VA Patient-Centered Community Care|VA Community Care|negotiated_dollar,standard_charge|VA Patient-Centered Community Care|VA Community Care|negotiated_percentage,standard_charge|VA Patient-Centered Community Care|VA Community Care|negotiated_algorithm,standard_charge|VA Patient-Centered Community Care|VA Community Care|methodology,estimated_amount|VA Patient-Centered Community Care|VA Community Care,additional_payer_notes|VA Patient-Centered Community Care|VA Community Care,standard_charge|Value Options|Value Options|negotiated_dollar,standard_charge|Value Options|Value Options|negotiated_percentage,standard_charge|Value Options|Value Options|negotiated_algorithm,standard_charge|Value Options|Value Options|methodology,estimated_amount|Value Options|Value Options,additional_payer_notes|Value Options|Value Options,standard_charge|Veterans Administration|Veterans Administration|negotiated_dollar,standard_charge|Veterans Administration|Veterans Administration|negotiated_percentage,standard_charge|Veterans Administration|Veterans Administration|negotiated_algorithm,standard_charge|Veterans Administration|Veterans Administration|methodology,estimated_amount|Veterans Administration|Veterans Administration,additional_payer_notes|Veterans Administration|Veterans Administration,standard_charge|Workers Comp|Workers Comp|negotiated_dollar,standard_charge|Workers Comp|Workers Comp|negotiated_percentage,standard_charge|Workers Comp|Workers Comp|negotiated_algorithm,standard_charge|Workers Comp|Workers Comp|methodology,estimated_amount|Workers Comp|Workers Comp,additional_payer_notes|Workers Comp|Workers Comp
R&B - PRIVATE,1140530110,CDM,110,RC,,,,,,,,inpatient,facility,,,1089.92,1089.92,87.19,6862.23,,1089.92,,,case rate,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,980.93,,,percent of total billed charges,,,,,,,,,1089.92,,,percent of total billed charges,,,603.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.44,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,568.28,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,217.98,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,87.19,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,case rate,,,926.43,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.96,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,765.34,,,percent of total billed charges,,
R&B - SEMIPRIVATE,1140530120,CDM,120,RC,,,,,,,,inpatient,facility,,,1089.92,1089.92,87.19,6862.23,,1089.92,,,case rate,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,980.93,,,percent of total billed charges,,,,,,,,,1089.92,,,percent of total billed charges,,,603.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.44,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,568.28,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,217.98,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,87.19,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,case rate,,,926.43,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.96,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,765.34,,,percent of total billed charges,,
R&B PRIVATE ISOLATION,1140530164,CDM,164,RC,,,,,,,,inpatient,facility,,,2410,2410,192.8,6862.23,,2410,,,case rate,,,,,,,,,2410,,,percent of total billed charges,,,2410,,,case rate,,,2410,,,case rate,,,,,,,,,2410,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,2169,,,percent of total billed charges,,,,,,,,,2410,,,percent of total billed charges,,,1334.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2198.88,,,percent of total billed charges,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,2410,,,case rate,,,2410,,,case rate,,,,,,,,,,,,,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,2410,,,percent of total billed charges,,,1256.57,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,482,,,percent of total billed charges,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,192.8,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,2410,,,case rate,,,2048.5,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,2410,,,case rate,,,2410,,,case rate,,,2410,,,case rate,,,,,,,,,2410,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1205,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1692.3,,,percent of total billed charges,,
R&B - PRIVATE,1140535110,CDM,110,RC,,,,,,,,inpatient,facility,,,1089.92,1089.92,87.19,6862.23,,1089.92,,,case rate,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,980.93,,,percent of total billed charges,,,,,,,,,1089.92,,,percent of total billed charges,,,603.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.44,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,568.28,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,217.98,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,87.19,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,case rate,,,926.43,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.96,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,765.34,,,percent of total billed charges,,
R&B - PRIVATE- TELEMETRY,1140535119,CDM,110,RC,,,,,,,,inpatient,facility,,,1416.9,1416.9,113.35,6862.23,,1416.9,,,case rate,,,,,,,,,1416.9,,,percent of total billed charges,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,1416.9,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,1275.21,,,percent of total billed charges,,,,,,,,,1416.9,,,percent of total billed charges,,,784.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1292.78,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,738.77,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,283.38,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,113.35,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,case rate,,,1204.37,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1416.9,,,case rate,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,1416.9,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.45,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,994.95,,,percent of total billed charges,,
R&B - SEMIPRIVATE,1140535120,CDM,120,RC,,,,,,,,inpatient,facility,,,1089.92,1089.92,87.19,6862.23,,1089.92,,,case rate,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,980.93,,,percent of total billed charges,,,,,,,,,1089.92,,,percent of total billed charges,,,603.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.44,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,568.28,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,217.98,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,87.19,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,case rate,,,926.43,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.96,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,765.34,,,percent of total billed charges,,
R&B - SEMIPRIVATE - TELEMETRY,1140535129,CDM,120,RC,,,,,,,,inpatient,facility,,,1416.9,1416.9,113.35,6862.23,,1416.9,,,case rate,,,,,,,,,1416.9,,,percent of total billed charges,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,1416.9,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,1275.21,,,percent of total billed charges,,,,,,,,,1416.9,,,percent of total billed charges,,,784.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1292.78,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,738.77,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,283.38,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,113.35,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,case rate,,,1204.37,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1416.9,,,case rate,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,1416.9,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.45,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,994.95,,,percent of total billed charges,,
R&B PRIVATE ISOLATION,1140535164,CDM,164,RC,,,,,,,,inpatient,facility,,,2410,2410,192.8,6862.23,,2410,,,case rate,,,,,,,,,2410,,,percent of total billed charges,,,2410,,,case rate,,,2410,,,case rate,,,,,,,,,2410,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,2169,,,percent of total billed charges,,,,,,,,,2410,,,percent of total billed charges,,,1334.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2198.88,,,percent of total billed charges,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,2410,,,case rate,,,2410,,,case rate,,,,,,,,,,,,,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,2410,,,percent of total billed charges,,,1256.57,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,482,,,percent of total billed charges,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,192.8,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,2410,,,case rate,,,2048.5,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,2410,,,case rate,,,2410,,,case rate,,,2410,,,case rate,,,,,,,,,2410,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1205,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1692.3,,,percent of total billed charges,,
R&B ISOLATION TELEMETRY,1140535169,CDM,164,RC,,,,,,,,inpatient,facility,,,3133,3133,250.64,6862.23,,3133,,,case rate,,,,,,,,,3133,,,percent of total billed charges,,,3133,,,case rate,,,3133,,,case rate,,,,,,,,,3133,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,2819.7,,,percent of total billed charges,,,,,,,,,3133,,,percent of total billed charges,,,1734.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2858.55,,,percent of total billed charges,,,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,3133,,,case rate,,,3133,,,case rate,,,,,,,,,,,,,,,3133,,,percent of total billed charges,,,,,,,,,,,,,,,3133,,,percent of total billed charges,,,1633.55,,,percent of total billed charges,,,3133,,,percent of total billed charges,,,3133,,,percent of total billed charges,,,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,626.6,,,percent of total billed charges,,,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,250.64,,,percent of total billed charges,,,3133,,,percent of total billed charges,,,3133,,,percent of total billed charges,,,,,,,,,,,,,,,3133,,,percent of total billed charges,,,3133,,,percent of total billed charges,,,,,,,,,,,,,,,3133,,,case rate,,,2663.05,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,3133,,,case rate,,,3133,,,case rate,,,3133,,,case rate,,,,,,,,,3133,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3133,,,percent of total billed charges,,,3133,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1566.5,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2199.99,,,percent of total billed charges,,
R&B - PRIVATE,1140540110,CDM,110,RC,,,,,,,,inpatient,facility,,,1089.92,1089.92,87.19,6862.23,,1089.92,,,case rate,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,980.93,,,percent of total billed charges,,,,,,,,,1089.92,,,percent of total billed charges,,,603.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.44,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,568.28,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,217.98,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,87.19,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,case rate,,,926.43,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.96,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,765.34,,,percent of total billed charges,,
R&B - SEMIPRIVATE,1140540120,CDM,120,RC,,,,,,,,inpatient,facility,,,1048,1048,83.84,6862.23,,1048,,,case rate,,,,,,,,,1048,,,percent of total billed charges,,,1048,,,case rate,,,1048,,,case rate,,,,,,,,,1048,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2096,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2096,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2096,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,943.2,,,percent of total billed charges,,,,,,,,,1048,,,percent of total billed charges,,,580.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,956.2,,,percent of total billed charges,,,2096,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1048,,,case rate,,,1048,,,case rate,,,,,,,,,,,,,,,1048,,,percent of total billed charges,,,,,,,,,,,,,,,1048,,,percent of total billed charges,,,546.43,,,percent of total billed charges,,,1048,,,percent of total billed charges,,,1048,,,percent of total billed charges,,,2096,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2096,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2096,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2096,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2096,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,209.6,,,percent of total billed charges,,,2096,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2096,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2096,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2096,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,83.84,,,percent of total billed charges,,,1048,,,percent of total billed charges,,,1048,,,percent of total billed charges,,,,,,,,,,,,,,,1048,,,percent of total billed charges,,,1048,,,percent of total billed charges,,,,,,,,,,,,,,,1048,,,case rate,,,890.8,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1048,,,case rate,,,1048,,,case rate,,,1048,,,case rate,,,,,,,,,1048,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1048,,,percent of total billed charges,,,1048,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,524,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,735.91,,,percent of total billed charges,,
R&B PRIVATE ISOLATION,1140540164,CDM,164,RC,,,,,,,,inpatient,facility,,,2410,2410,192.8,6862.23,,2410,,,case rate,,,,,,,,,2410,,,percent of total billed charges,,,2410,,,case rate,,,2410,,,case rate,,,,,,,,,2410,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,2169,,,percent of total billed charges,,,,,,,,,2410,,,percent of total billed charges,,,1334.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2198.88,,,percent of total billed charges,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,2410,,,case rate,,,2410,,,case rate,,,,,,,,,,,,,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,2410,,,percent of total billed charges,,,1256.57,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,482,,,percent of total billed charges,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,192.8,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,2410,,,case rate,,,2048.5,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,2410,,,case rate,,,2410,,,case rate,,,2410,,,case rate,,,,,,,,,2410,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1205,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1692.3,,,percent of total billed charges,,
R&B SEMI-PRIVATE DETOX,1143005126,CDM,126,RC,,,,,,,,inpatient,facility,,,1290,1290,103.2,6862.23,,1290,,,case rate,,,,,,,,,1290,,,percent of total billed charges,,,1290,,,case rate,,,1290,,,case rate,,,,,,,,,1290,,,case rate,,,1915.65,,,per diem,,,896.5,,,per diem,,,1564.3,,,per diem,,,675,,,per diem,,,,,,,,,2580,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2580,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2580,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,1161,,,percent of total billed charges,,,,,,,,,1290,,,percent of total billed charges,,,714.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1177,,,percent of total billed charges,,,2580,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1290,,,per diem,,,1290,,,per diem,,,,,,,,,,,,,,,1290,,,percent of total billed charges,,,,,,,,,,,,,,,1290,,,percent of total billed charges,,,672.61,,,percent of total billed charges,,,815,,,per diem,,,815,,,per diem,,,2580,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2580,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,980.4,,,percent of total billed charges,,,2580,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2580,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2580,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,258,,,percent of total billed charges,,,2580,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2580,,,per diem,,,2580,,,per diem,,,2580,,,per diem,,,,,,,,,,,,,,,103.2,,,percent of total billed charges,,,1290,,,percent of total billed charges,,,1290,,,percent of total billed charges,,,,,,,,,,,,,,,2200,,,per diem,,,1290,,,percent of total billed charges,,,,,,,,,,,,,,,1290,,,per diem,,,1096.5,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1290,,,per diem,,,1290,,,per diem,,,1290,,,per diem,,,,,,,,,1290,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1290,,,percent of total billed charges,,,1290,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,645,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,905.84,,,percent of total billed charges,,
WEEKDAY ADMISSION DAY,1143005900,CDM,900,RC,,,,,,,,inpatient,facility,,,2975,2975,238,2975,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2677.5,,,percent of total billed charges,,,,,,,,,2975,,,percent of total billed charges,,,1646.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2714.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,1551.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,595,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2089.04,,,percent of total billed charges,,
WEEKDAY ADMISSION DAY,1143005900,CDM,900,RC,,,,,,,,outpatient,facility,,,2975,2975,238,2975,,1737.4,,,percent of total billed charges,,,580.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2975,,,percent of total billed charges,,,2619.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2619.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2619.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1088.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2677.5,,,percent of total billed charges,,,,,,,,,2975,,,percent of total billed charges,,,2014.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2284.8,,,percent of total billed charges,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,,1606.5,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1551.16,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2261,,,percent of total billed charges,,,1126.93,,,percent of total billed charges,,,1540.75,,,percent of total billed charges,,,,,,,,,,,,,,,595,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1100.75,,,percent of total billed charges,,,1100.75,,,percent of total billed charges,,,2975,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2975,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,238,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,,,,,,,2975,,,fee schedule,,,2767.34,,,percent of total billed charges,,,,,,,,,,,,,,,2767.34,,,percent of total billed charges,,,2767.34,,,percent of total billed charges,,,2767.34,,,percent of total billed charges,,,2231.25,,,percent of total billed charges,,,2975,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2975,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1487.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2089.05,,,percent of total billed charges,,
WEEKDAY ADMISSION DAY,1143005900,CDM,900,RC,999,EAPG,,,,,,outpatient,facility,,,2975,2975,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEEKEND ADMISSION DAY,1143005919,CDM,919,RC,,,,,,,,inpatient,facility,,,3625,3625,290,3625,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3262.5,,,percent of total billed charges,,,,,,,,,3625,,,percent of total billed charges,,,2006.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3307.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,1890.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,725,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2545.47,,,percent of total billed charges,,
WEEKEND ADMISSION DAY,1143005919,CDM,919,RC,,,,,,,,outpatient,facility,,,3625,3625,290,3625,,2117,,,percent of total billed charges,,,706.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3625,,,percent of total billed charges,,,3191.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3191.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3191.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1326.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3262.5,,,percent of total billed charges,,,,,,,,,3625,,,percent of total billed charges,,,2454.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2784,,,percent of total billed charges,,,,,,,,,,,,,,,1957.5,,,percent of total billed charges,,,1957.5,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1890.07,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2755,,,percent of total billed charges,,,1373.15,,,percent of total billed charges,,,1877.39,,,percent of total billed charges,,,,,,,,,,,,,,,725,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1341.25,,,percent of total billed charges,,,1341.25,,,percent of total billed charges,,,3625,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3625,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,290,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,,,,,,,3625,,,fee schedule,,,3371.97,,,percent of total billed charges,,,,,,,,,,,,,,,3371.97,,,percent of total billed charges,,,3371.97,,,percent of total billed charges,,,3371.97,,,percent of total billed charges,,,2718.75,,,percent of total billed charges,,,3625,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3625,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2545.47,,,percent of total billed charges,,
WEEKEND ADMISSION DAY,1143005919,CDM,919,RC,999,EAPG,,,,,,outpatient,facility,,,3625,3625,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
R&B - PRIVATE - PSYCH,1143020114,CDM,114,RC,,,,,,,,inpatient,facility,,,1048,1048,83.84,2096,,1588,,,per diem,,,,,,,,,1048,,,percent of total billed charges,,,1048,,,case rate,,,1048,,,case rate,,,,,,,,,1048,,,case rate,,,1046.28,,,per diem,,,960,,,per diem,,,804.83,,,per diem,,,900,,,per diem,,,,,,,,,2096,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.4660 ) ,other,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.4660 ) ,2096,,,per diem,,,2096,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.3033 ) ,other,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.3033 ) ,,,,,,,956.82,,,per diem,,,,,,,,,1016.05,,,per diem,,,943.2,,,percent of total billed charges,,,,,,,,,1048,,,percent of total billed charges,,,580.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,956.2,,,percent of total billed charges,,,2096,,,per diem,,,,,,,,,1048,,,per diem,,,1048,,,per diem,,,,,,,,,,,,,,,1048,,,percent of total billed charges,,,,,,,,,,,,,,,1048,,,percent of total billed charges,,,546.43,,,percent of total billed charges,,,1048,,,percent of total billed charges,,,1048,,,percent of total billed charges,,,2096,,,per diem,,,2096,,,per diem,,,954.59,,,per diem,,,,,,,,,,,,,,,1300,,,per diem,,,2096,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2096,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2096,,,per diem,,,,,,,,,209.6,,,percent of total billed charges,,,2096,,,per diem,,,2096,,,per diem,,,2096,,,per diem,,,2096,,,per diem,,,,,,,,,,,,,,,83.84,,,percent of total billed charges,,,1048,,,percent of total billed charges,,,1048,,,percent of total billed charges,,,,,,,,,,,,,,,1050,,,per diem,,,1048,,,percent of total billed charges,,,,,,,,,,,,,,,1048,,,per diem,,,890.8,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1048,,,per diem,,,1048,,,per diem,,,1048,,,per diem,,,,,,,,,1048,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1048,,,percent of total billed charges,,,1048,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,902,,,per diem,,,,,,,,,735.91,,,percent of total billed charges,,
R&B - SEMIPRIVATE - PSYCH,1143020124,CDM,124,RC,,,,,,,,inpatient,facility,,,1089.92,1089.92,87.19,2179.84,,1588,,,per diem,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,,case rate,,,1046.28,,,per diem,,,960,,,per diem,,,804.83,,,per diem,,,900,,,per diem,,,,,,,,,2179.84,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.4660 ) ,other,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.4660 ) ,2179.84,,,per diem,,,2179.84,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.3033 ) ,other,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.3033 ) ,,,,,,,956.82,,,per diem,,,,,,,,,1016.05,,,per diem,,,980.93,,,percent of total billed charges,,,,,,,,,1089.92,,,percent of total billed charges,,,603.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.44,,,percent of total billed charges,,,2179.84,,,per diem,,,,,,,,,1089.92,,,per diem,,,1089.92,,,per diem,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,568.28,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,2179.84,,,per diem,,,2179.84,,,per diem,,,954.59,,,per diem,,,,,,,,,,,,,,,828.34,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,,per diem,,,,,,,,,217.98,,,percent of total billed charges,,,2179.84,,,per diem,,,2179.84,,,per diem,,,2179.84,,,per diem,,,2179.84,,,per diem,,,,,,,,,,,,,,,87.19,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1050,,,per diem,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,per diem,,,926.43,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1089.92,,,per diem,,,1089.92,,,per diem,,,1089.92,,,per diem,,,,,,,,,1089.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,902,,,per diem,,,,,,,,,765.34,,,percent of total billed charges,,
WEEKDAY ADMISSION DAY,1143020900,CDM,900,RC,,,,,,,,inpatient,facility,,,2975,2975,238,2975,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2677.5,,,percent of total billed charges,,,,,,,,,2975,,,percent of total billed charges,,,1646.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2714.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,1551.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,595,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2089.04,,,percent of total billed charges,,
WEEKDAY ADMISSION DAY,1143020900,CDM,900,RC,,,,,,,,outpatient,facility,,,2975,2975,238,2975,,1737.4,,,percent of total billed charges,,,580.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2975,,,percent of total billed charges,,,2619.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2619.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2619.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1088.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2677.5,,,percent of total billed charges,,,,,,,,,2975,,,percent of total billed charges,,,2014.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2284.8,,,percent of total billed charges,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,,1606.5,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1551.16,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2261,,,percent of total billed charges,,,1126.93,,,percent of total billed charges,,,1540.75,,,percent of total billed charges,,,,,,,,,,,,,,,595,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1100.75,,,percent of total billed charges,,,1100.75,,,percent of total billed charges,,,2975,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2975,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,238,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,,,,,,,2975,,,fee schedule,,,2767.34,,,percent of total billed charges,,,,,,,,,,,,,,,2767.34,,,percent of total billed charges,,,2767.34,,,percent of total billed charges,,,2767.34,,,percent of total billed charges,,,2231.25,,,percent of total billed charges,,,2975,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2975,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1487.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2089.05,,,percent of total billed charges,,
WEEKDAY ADMISSION DAY,1143020900,CDM,900,RC,999,EAPG,,,,,,outpatient,facility,,,2975,2975,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEEKEND ADMISSION DAY,1143020919,CDM,919,RC,,,,,,,,inpatient,facility,,,3625,3625,290,3625,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3262.5,,,percent of total billed charges,,,,,,,,,3625,,,percent of total billed charges,,,2006.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3307.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,1890.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,725,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2545.47,,,percent of total billed charges,,
WEEKEND ADMISSION DAY,1143020919,CDM,919,RC,,,,,,,,outpatient,facility,,,3625,3625,290,3625,,2117,,,percent of total billed charges,,,706.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3625,,,percent of total billed charges,,,3191.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3191.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3191.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1326.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3262.5,,,percent of total billed charges,,,,,,,,,3625,,,percent of total billed charges,,,2454.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2784,,,percent of total billed charges,,,,,,,,,,,,,,,1957.5,,,percent of total billed charges,,,1957.5,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1890.07,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2755,,,percent of total billed charges,,,1373.15,,,percent of total billed charges,,,1877.39,,,percent of total billed charges,,,,,,,,,,,,,,,725,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1341.25,,,percent of total billed charges,,,1341.25,,,percent of total billed charges,,,3625,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3625,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,290,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,,,,,,,3625,,,fee schedule,,,3371.97,,,percent of total billed charges,,,,,,,,,,,,,,,3371.97,,,percent of total billed charges,,,3371.97,,,percent of total billed charges,,,3371.97,,,percent of total billed charges,,,2718.75,,,percent of total billed charges,,,3625,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3625,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2545.47,,,percent of total billed charges,,
WEEKEND ADMISSION DAY,1143020919,CDM,919,RC,999,EAPG,,,,,,outpatient,facility,,,3625,3625,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
R&B - PRIVATE,1143760110,CDM,110,RC,,,,,,,,inpatient,facility,,,1089.92,1089.92,87.19,6862.23,,1089.92,,,case rate,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,980.93,,,percent of total billed charges,,,,,,,,,1089.92,,,percent of total billed charges,,,603.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.44,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,568.28,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,217.98,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,87.19,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,case rate,,,926.43,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.96,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,765.34,,,percent of total billed charges,,
R&B - PRIVATE - TELEMETRY,1143760119,CDM,110,RC,,,,,,,,inpatient,facility,,,1416.9,1416.9,113.35,6862.23,,1416.9,,,case rate,,,,,,,,,1416.9,,,percent of total billed charges,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,1416.9,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,1275.21,,,percent of total billed charges,,,,,,,,,1416.9,,,percent of total billed charges,,,784.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1292.78,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,738.77,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,283.38,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,113.35,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,case rate,,,1204.37,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1416.9,,,case rate,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,1416.9,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.45,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,994.95,,,percent of total billed charges,,
R&B - SEMIPRIVATE,1143760120,CDM,120,RC,,,,,,,,inpatient,facility,,,1089.92,1089.92,87.19,6862.23,,1089.92,,,case rate,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,980.93,,,percent of total billed charges,,,,,,,,,1089.92,,,percent of total billed charges,,,603.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.44,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,568.28,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,217.98,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,87.19,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,case rate,,,926.43,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.96,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,765.34,,,percent of total billed charges,,
R&B ICU,1143760200,CDM,200,RC,,,,,,,,inpatient,facility,,,2724.8,2724.8,217.98,6862.23,,2724.8,,,case rate,,,,,,,,,2724.8,,,percent of total billed charges,,,2724.8,,,case rate,,,2724.8,,,case rate,,,,,,,,,2724.8,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5449.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,5449.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,5449.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,2452.32,,,percent of total billed charges,,,,,,,,,2724.8,,,percent of total billed charges,,,1508.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2486.11,,,percent of total billed charges,,,5449.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,2724.8,,,case rate,,,2724.8,,,case rate,,,,,,,,,,,,,,,2724.8,,,percent of total billed charges,,,,,,,,,,,,,,,2724.8,,,percent of total billed charges,,,1420.71,,,percent of total billed charges,,,2724.8,,,percent of total billed charges,,,2724.8,,,percent of total billed charges,,,5449.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,5449.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1550,,,per diem,,,5449.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,5449.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,5449.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,544.96,,,percent of total billed charges,,,5449.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,5449.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,5449.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,5449.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,217.98,,,percent of total billed charges,,,2724.8,,,percent of total billed charges,,,2724.8,,,percent of total billed charges,,,,,,,,,,,,,,,2724.8,,,percent of total billed charges,,,2724.8,,,percent of total billed charges,,,,,,,,,,,,,,,2724.8,,,case rate,,,2316.08,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,2724.8,,,case rate,,,2724.8,,,case rate,,,2724.8,,,case rate,,,,,,,,,2724.8,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2724.8,,,percent of total billed charges,,,2724.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1362.4,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1913.35,,,percent of total billed charges,,
R&B ICU/CCU ISOLATION,1143760209,CDM,200,RC,,,,,,,,inpatient,facility,,,6095,6095,487.6,12190,,6095,,,case rate,,,,,,,,,6095,,,percent of total billed charges,,,6095,,,case rate,,,6095,,,case rate,,,,,,,,,6095,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12190,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,12190,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,12190,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,5485.5,,,percent of total billed charges,,,,,,,,,6095,,,percent of total billed charges,,,3374.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5561.08,,,percent of total billed charges,,,12190,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,6095,,,case rate,,,6095,,,case rate,,,,,,,,,,,,,,,6095,,,percent of total billed charges,,,,,,,,,,,,,,,6095,,,percent of total billed charges,,,3177.93,,,percent of total billed charges,,,6095,,,percent of total billed charges,,,6095,,,percent of total billed charges,,,12190,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,12190,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1550,,,per diem,,,12190,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,12190,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,12190,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1219,,,percent of total billed charges,,,12190,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,12190,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,12190,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,12190,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,487.6,,,percent of total billed charges,,,6095,,,percent of total billed charges,,,6095,,,percent of total billed charges,,,,,,,,,,,,,,,6095,,,percent of total billed charges,,,6095,,,percent of total billed charges,,,,,,,,,,,,,,,6095,,,case rate,,,5180.75,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,6095,,,case rate,,,6095,,,case rate,,,6095,,,case rate,,,,,,,,,6095,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6095,,,percent of total billed charges,,,6095,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3047.5,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4279.91,,,percent of total billed charges,,
R&B - PRIVATE,1143795110,CDM,110,RC,,,,,,,,inpatient,facility,,,1089.92,1089.92,87.19,6862.23,,1089.92,,,case rate,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,980.93,,,percent of total billed charges,,,,,,,,,1089.92,,,percent of total billed charges,,,603.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.44,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,568.28,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,217.98,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,87.19,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,case rate,,,926.43,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.96,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,765.34,,,percent of total billed charges,,
R&B - PRIVATE - TELEMETRY,1143795119,CDM,110,RC,,,,,,,,inpatient,facility,,,1416.9,1416.9,113.35,6862.23,,1416.9,,,case rate,,,,,,,,,1416.9,,,percent of total billed charges,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,1416.9,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,1275.21,,,percent of total billed charges,,,,,,,,,1416.9,,,percent of total billed charges,,,784.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1292.78,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,738.77,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,283.38,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,113.35,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,case rate,,,1204.37,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1416.9,,,case rate,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,1416.9,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.45,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,994.95,,,percent of total billed charges,,
R&B - SEMIPRIVATE,1143795120,CDM,120,RC,,,,,,,,inpatient,facility,,,1089.92,1089.92,87.19,6862.23,,1089.92,,,case rate,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,980.93,,,percent of total billed charges,,,,,,,,,1089.92,,,percent of total billed charges,,,603.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.44,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,568.28,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,217.98,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,87.19,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,case rate,,,926.43,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.96,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,765.34,,,percent of total billed charges,,
R&B - SEMIPRIVATE - TELEMETRY,1143795129,CDM,120,RC,,,,,,,,inpatient,facility,,,1416.9,1416.9,113.35,6862.23,,1416.9,,,case rate,,,,,,,,,1416.9,,,percent of total billed charges,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,1416.9,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,1275.21,,,percent of total billed charges,,,,,,,,,1416.9,,,percent of total billed charges,,,784.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1292.78,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,738.77,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,283.38,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,113.35,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,case rate,,,1204.37,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1416.9,,,case rate,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,1416.9,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.45,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,994.95,,,percent of total billed charges,,
R&B PRIVATE ISOLATION,1143795164,CDM,164,RC,,,,,,,,inpatient,facility,,,2410,2410,192.8,6862.23,,2410,,,case rate,,,,,,,,,2410,,,percent of total billed charges,,,2410,,,case rate,,,2410,,,case rate,,,,,,,,,2410,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,2169,,,percent of total billed charges,,,,,,,,,2410,,,percent of total billed charges,,,1334.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2198.88,,,percent of total billed charges,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,2410,,,case rate,,,2410,,,case rate,,,,,,,,,,,,,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,2410,,,percent of total billed charges,,,1256.57,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,482,,,percent of total billed charges,,,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,4820,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,192.8,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,2410,,,case rate,,,2048.5,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,2410,,,case rate,,,2410,,,case rate,,,2410,,,case rate,,,,,,,,,2410,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2410,,,percent of total billed charges,,,2410,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1205,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1692.3,,,percent of total billed charges,,
R&B ISOLATION TELEMETRY,1143795169,CDM,164,RC,,,,,,,,inpatient,facility,,,3133,3133,250.64,6862.23,,3133,,,case rate,,,,,,,,,3133,,,percent of total billed charges,,,3133,,,case rate,,,3133,,,case rate,,,,,,,,,3133,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,2819.7,,,percent of total billed charges,,,,,,,,,3133,,,percent of total billed charges,,,1734.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2858.55,,,percent of total billed charges,,,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,3133,,,case rate,,,3133,,,case rate,,,,,,,,,,,,,,,3133,,,percent of total billed charges,,,,,,,,,,,,,,,3133,,,percent of total billed charges,,,1633.55,,,percent of total billed charges,,,3133,,,percent of total billed charges,,,3133,,,percent of total billed charges,,,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,626.6,,,percent of total billed charges,,,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,6266,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,250.64,,,percent of total billed charges,,,3133,,,percent of total billed charges,,,3133,,,percent of total billed charges,,,,,,,,,,,,,,,3133,,,percent of total billed charges,,,3133,,,percent of total billed charges,,,,,,,,,,,,,,,3133,,,case rate,,,2663.05,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,3133,,,case rate,,,3133,,,case rate,,,3133,,,case rate,,,,,,,,,3133,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3133,,,percent of total billed charges,,,3133,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1566.5,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2199.99,,,percent of total billed charges,,
R&B - PRIVATE,1150150110,CDM,110,RC,,,,,,,,inpatient,facility,,,1089.92,1089.92,87.19,6862.23,,1089.92,,,case rate,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,980.93,,,percent of total billed charges,,,,,,,,,1089.92,,,percent of total billed charges,,,603.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.44,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,568.28,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,217.98,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,87.19,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,case rate,,,926.43,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.96,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,765.34,,,percent of total billed charges,,
R&B - PRIVATE- TELEMETRY,1150150119,CDM,110,RC,,,,,,,,inpatient,facility,,,1416.9,1416.9,113.35,6862.23,,1416.9,,,case rate,,,,,,,,,1416.9,,,percent of total billed charges,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,1416.9,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,1275.21,,,percent of total billed charges,,,,,,,,,1416.9,,,percent of total billed charges,,,784.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1292.78,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,738.77,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,283.38,,,percent of total billed charges,,,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2833.8,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,113.35,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,1416.9,,,case rate,,,1204.37,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1416.9,,,case rate,,,1416.9,,,case rate,,,1416.9,,,case rate,,,,,,,,,1416.9,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1416.9,,,percent of total billed charges,,,1416.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.45,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,994.95,,,percent of total billed charges,,
R&B - SEMIPRIVATE,1150150120,CDM,120,RC,,,,,,,,inpatient,facility,,,1089.92,1089.92,87.19,6862.23,,1089.92,,,case rate,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,980.93,,,percent of total billed charges,,,,,,,,,1089.92,,,percent of total billed charges,,,603.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.44,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,568.28,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1300,,,per diem,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,217.98,,,percent of total billed charges,,,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2179.84,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,87.19,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,1089.92,,,case rate,,,926.43,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1089.92,,,case rate,,,1089.92,,,case rate,,,1089.92,,,case rate,,,,,,,,,1089.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1089.92,,,percent of total billed charges,,,1089.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.96,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,765.34,,,percent of total billed charges,,
R&B ICU,1150150200,CDM,200,RC,,,,,,,,inpatient,facility,,,2189,2189,175.12,6862.23,,2189,,,case rate,,,,,,,,,2189,,,percent of total billed charges,,,2189,,,case rate,,,2189,,,case rate,,,,,,,,,2189,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4378,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,4378,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,4378,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,6862.23,,,case rate,,,,,,,,,,,,,,service not payable,1970.1,,,percent of total billed charges,,,,,,,,,2189,,,percent of total billed charges,,,1211.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.24,,,percent of total billed charges,,,4378,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,2189,,,case rate,,,2189,,,case rate,,,,,,,,,,,,,,,2189,,,percent of total billed charges,,,,,,,,,,,,,,,2189,,,percent of total billed charges,,,1141.34,,,percent of total billed charges,,,2189,,,percent of total billed charges,,,2189,,,percent of total billed charges,,,4378,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11612.00 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,4378,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12282.03  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,service not payable,,,,,,,,,,,,,1550,,,per diem,,,4378,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 14096.91  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,4378,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19567.19  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6204 ) ,4378,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11612.00  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6669 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,437.8,,,percent of total billed charges,,,4378,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 10027.83  Plus:    $24.10 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 24000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.877 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,4378,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12282.03 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.00   ) ,4378,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28322.11 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,4378,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15352.36 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.6211 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,,,,,,,175.12,,,percent of total billed charges,,,2189,,,percent of total billed charges,,,2189,,,percent of total billed charges,,,,,,,,,,,,,,,2189,,,percent of total billed charges,,,2189,,,percent of total billed charges,,,,,,,,,,,,,,,2189,,,case rate,,,1860.65,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220073   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,2189,,,case rate,,,2189,,,case rate,,,2189,,,case rate,,,,,,,,,2189,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2189,,,percent of total billed charges,,,2189,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1094.5,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1537.12,,,percent of total billed charges,,
KEDRAB 300 UNITS/2 ML INJ,2500000007,CDM,636,RC,90377,CPT,4928119020,NDC,,,,inpatient,facility,2,ML,2986.92,2986.92,238.95,2986.92,,,,,,,,,,,,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2688.23,,,percent of total billed charges,,,,,,,,,2986.92,,,percent of total billed charges,,,1653.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2725.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,2986.92,,,percent of total billed charges,,,1557.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,597.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.95,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2097.42,,,percent of total billed charges,,
KEDRAB 300 UNITS/2 ML INJ,2500000007,CDM,636,RC,90377,CPT,4928119020,NDC,,,,outpatient,facility,2,ML,2986.92,2986.92,160.84,2986.92,,1744.36,,,percent of total billed charges,,,,,,,,,2986.92,,,percent of total billed charges,,,307.84,,,fee schedule,,,296.64,,,fee schedule,,,,,,,,,296.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2688.23,,,percent of total billed charges,,,,,,,,,2986.92,,,percent of total billed charges,,,2022.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2293.95,,,percent of total billed charges,,,,,,,,,,,,,,,256.31,,,fee schedule,,,256.31,,,fee schedule,,,,,,,,,618.77,,,per diem,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1557.38,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2270.06,,,percent of total billed charges,,,1131.45,,,percent of total billed charges,,,1546.93,,,percent of total billed charges,,,,,,,,,,,,,,,597.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,520.1,,,fee schedule,,,231.89,,,fee schedule,,,,,,,,,,,,,,,238.95,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,2986.92,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,,,,,,,2986.92,,,fee schedule,,,247.44,,,fee schedule,,,,,,,,,,,,,,,217.59,,,fee schedule,,,290.12,,,fee schedule,,,160.84,,,fee schedule,,,270.26,,,fee schedule,,,2986.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2986.92,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1493.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2097.42,,,percent of total billed charges,,
KEDRAB 300 UNITS/2 ML INJ,2500000007,CDM,636,RC,90377,CPT,4928119020,NDC,9201,APC,,outpatient,facility,2,ML,2986.92,2986.92,240.5,1093.21,,,,,,,,258.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.03,,,fee schedule,,,,,,,,,1093.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,,,,,,,250.52,,,fee schedule,,,263.05,,,fee schedule,,,,,,,,,250.52,,,fee schedule,,,250.52,,,fee schedule,,,263.05,,,fee schedule,,,,,,,,,,,,,,,363.25,,,fee schedule,,,,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,,,,,,,240.5,,,fee schedule,,,268.06,,,fee schedule,,,263.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.52,,,fee schedule,,,250.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,260.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,313.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,250.52,,,fee schedule,,,250.52,,,fee schedule,,,,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,,,,,,,250.52,,,fee schedule,,,258.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.51,,,fee schedule,,,250.52,,,fee schedule,,,260.54,,,fee schedule,,,250.52,,,fee schedule,,,,,,,,,250.52,,,fee schedule,,,,,,,,,250.52,,,fee schedule,,,,,,,,
KEDRAB 300 UNITS/2 ML INJ,2500000007,CDM,636,RC,90377,CPT,4928119020,NDC,999,EAPG,,outpatient,facility,2,ML,2986.92,2986.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NYSTATIN 60 GM POWDER,2500000177,CDM,637,RC,574200802,NDC,,,,,,inpatient,facility,60,UN,316.4,316.4,25.31,316.4,,,,,,,,,,,,,,316.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284.76,,,percent of total billed charges,,,,,,,,,316.4,,,percent of total billed charges,,,175.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.4,,,percent of total billed charges,,,,,,,,,,,,,,,316.4,,,percent of total billed charges,,,164.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.31,,,percent of total billed charges,,,316.4,,,percent of total billed charges,,,316.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,316.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.18,,,percent of total billed charges,,
NYSTATIN 60 GM POWDER,2500000177,CDM,637,RC,574200802,NDC,,,,,,outpatient,facility,60,UN,316.4,316.4,25.31,618.77,,184.78,,,percent of total billed charges,,,61.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,316.4,,,percent of total billed charges,,,278.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,278.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,278.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,316.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,115.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,284.76,,,percent of total billed charges,,,,,,,,,316.4,,,percent of total billed charges,,,214.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243,,,percent of total billed charges,,,,,,,,,,,,,,,170.86,,,percent of total billed charges,,,170.86,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,316.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.97,,,percent of total billed charges,,,316.4,,,percent of total billed charges,,,316.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.46,,,percent of total billed charges,,,119.85,,,percent of total billed charges,,,163.86,,,percent of total billed charges,,,,,,,,,,,,,,,63.28,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,117.07,,,percent of total billed charges,,,117.07,,,percent of total billed charges,,,316.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,316.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.31,,,percent of total billed charges,,,316.4,,,percent of total billed charges,,,316.4,,,percent of total billed charges,,,,,,,,,,,,,,,316.4,,,percent of total billed charges,,,316.4,,,percent of total billed charges,,,,,,,,,316.4,,,fee schedule,,,294.32,,,percent of total billed charges,,,,,,,,,,,,,,,294.32,,,percent of total billed charges,,,294.32,,,percent of total billed charges,,,294.32,,,percent of total billed charges,,,237.3,,,percent of total billed charges,,,316.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,316.4,,,percent of total billed charges,,,316.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,222.18,,,percent of total billed charges,,
NYSTATIN 60 GM POWDER,2500000177,CDM,637,RC,574200802,NDC,999,EAPG,,,,outpatient,facility,60,UN,316.4,316.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEP B VAC 20 MCG/ 1 ML INJ,2500000235,CDM,636,RC,90746,CPT,5816082111,NDC,,,,inpatient,facility,1,UN,226.84,226.84,18.15,226.84,,,,,,,,,,,,,,226.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,204.16,,,percent of total billed charges,,,,,,,,,226.84,,,percent of total billed charges,,,125.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.84,,,percent of total billed charges,,,,,,,,,,,,,,,226.84,,,percent of total billed charges,,,118.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.15,,,percent of total billed charges,,,226.84,,,percent of total billed charges,,,226.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,226.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.29,,,percent of total billed charges,,
HEP B VAC 20 MCG/ 1 ML INJ,2500000235,CDM,636,RC,90746,CPT,5816082111,NDC,,,,outpatient,facility,1,UN,226.84,226.84,18.15,618.77,,132.47,,,percent of total billed charges,,,66.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,226.84,,,percent of total billed charges,,,83.19,,,fee schedule,,,80.16,,,fee schedule,,,64.46,,,fee schedule,,,80.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,226.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.1,,,fee schedule,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,147.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,204.16,,,percent of total billed charges,,,64.46,,,fee schedule,,,226.84,,,percent of total billed charges,,,153.62,,,percent of total billed charges,,,67.69,,,fee schedule,,,67.68,,,fee schedule,,,,,,,,,64.46,,,fee schedule,,,64.46,,,fee schedule,,,67.68,,,fee schedule,,,174.21,,,percent of total billed charges,,,,,,,,,93.47,,,fee schedule,,,76.04,,,fee schedule,,,76.04,,,fee schedule,,,66.39,,,fee schedule,,,618.77,,,per diem,,,226.84,,,percent of total billed charges,,,62.2,,,fee schedule,,,68.97,,,fee schedule,,,69.07,,,fee schedule,,,118.27,,,percent of total billed charges,,,226.84,,,percent of total billed charges,,,226.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.46,,,fee schedule,,,64.46,,,fee schedule,,,172.4,,,percent of total billed charges,,,85.93,,,percent of total billed charges,,,117.48,,,percent of total billed charges,,,,,,,,,68.41,,,fee schedule,,,45.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,155.33,,,fee schedule,,,69.25,,,fee schedule,,,80.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,80.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.15,,,percent of total billed charges,,,226.84,,,percent of total billed charges,,,226.84,,,percent of total billed charges,,,64.46,,,fee schedule,,,64.46,,,fee schedule,,,226.84,,,percent of total billed charges,,,226.84,,,percent of total billed charges,,,64.46,,,fee schedule,,,70.38,,,fee schedule,,,73.9,,,fee schedule,,,64.46,,,fee schedule,,,66.39,,,fee schedule,,,64.98,,,fee schedule,,,86.64,,,fee schedule,,,48.04,,,fee schedule,,,73.03,,,fee schedule,,,226.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,226.84,,,percent of total billed charges,,,226.84,,,percent of total billed charges,,,123.83,,,fee schedule,,,64.46,,,fee schedule,,,68.74,,,fee schedule,,,64.46,,,fee schedule,,,73.34,,,fee schedule,,,65.78,,,fee schedule,,,113.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,65.78,,,fee schedule,,,,,,,,service not payable
HEP B VAC 20 MCG/ 1 ML INJ,2500000235,CDM,636,RC,90746,CPT,5816082111,NDC,414,EAPG,,outpatient,facility,1,UN,226.84,226.84,23.83,34.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.93,,,fee schedule,,,23.83,,,fee schedule,,,31.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RABIES VACCINE 2.5 IU SYR IM,2500000341,CDM,636,RC,90675,CPT,5816096412,NDC,,,,inpatient,facility,1,UN,1250.83,1250.83,100.07,1250.83,,,,,,,,,,,,,,1250.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.75,,,percent of total billed charges,,,,,,,,,1250.83,,,percent of total billed charges,,,692.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1250.83,,,percent of total billed charges,,,,,,,,,,,,,,,1250.83,,,percent of total billed charges,,,652.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.07,,,percent of total billed charges,,,1250.83,,,percent of total billed charges,,,1250.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1250.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.33,,,percent of total billed charges,,
RABIES VACCINE 2.5 IU SYR IM,2500000341,CDM,636,RC,90675,CPT,5816096412,NDC,,,,outpatient,facility,1,UN,1250.83,1250.83,100.07,1250.83,,730.48,,,percent of total billed charges,,,,,,,,,1250.83,,,percent of total billed charges,,,400.1,,,fee schedule,,,385.54,,,fee schedule,,,,,,,,,385.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1250.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1125.75,,,percent of total billed charges,,,,,,,,,1250.83,,,percent of total billed charges,,,847.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,960.64,,,percent of total billed charges,,,,,,,,,,,,,,,324.74,,,fee schedule,,,324.74,,,fee schedule,,,,,,,,,618.77,,,per diem,,,1250.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,652.18,,,percent of total billed charges,,,1250.83,,,percent of total billed charges,,,1250.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,950.63,,,percent of total billed charges,,,473.81,,,percent of total billed charges,,,647.8,,,percent of total billed charges,,,,,,,,,,,,,,,250.17,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,769.21,,,fee schedule,,,342.95,,,fee schedule,,,,,,,,,,,,,,,100.07,,,percent of total billed charges,,,1250.83,,,percent of total billed charges,,,1250.83,,,percent of total billed charges,,,,,,,,,,,,,,,1250.83,,,percent of total billed charges,,,1250.83,,,percent of total billed charges,,,,,,,,,1250.83,,,fee schedule,,,365.96,,,fee schedule,,,,,,,,,,,,,,,321.81,,,fee schedule,,,429.08,,,fee schedule,,,237.87,,,fee schedule,,,351.26,,,fee schedule,,,1250.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1250.83,,,percent of total billed charges,,,1250.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,625.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,service not payable
RABIES VACCINE 2.5 IU SYR IM,2500000341,CDM,636,RC,90675,CPT,5816096412,NDC,9139,APC,,outpatient,facility,1,UN,1250.83,1250.83,314.67,475.28,,,,,,,,337.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,327.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.06,,,fee schedule,,,,,,,,,457.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,327.78,,,fee schedule,,,,,,,,,,,,,,,327.78,,,fee schedule,,,344.17,,,fee schedule,,,,,,,,,327.78,,,fee schedule,,,327.78,,,fee schedule,,,344.17,,,fee schedule,,,,,,,,,,,,,,,475.28,,,fee schedule,,,,,,,,,,,,,,,327.78,,,fee schedule,,,,,,,,,,,,,,,314.67,,,fee schedule,,,350.72,,,fee schedule,,,344.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,327.78,,,fee schedule,,,327.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,409.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,409.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,327.78,,,fee schedule,,,327.78,,,fee schedule,,,,,,,,,,,,,,,327.78,,,fee schedule,,,,,,,,,,,,,,,327.78,,,fee schedule,,,337.61,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.14,,,fee schedule,,,327.78,,,fee schedule,,,340.89,,,fee schedule,,,327.78,,,fee schedule,,,,,,,,,327.78,,,fee schedule,,,,,,,,,327.78,,,fee schedule,,,,,,,,
RABIES VACCINE 2.5 IU SYR IM,2500000341,CDM,636,RC,90675,CPT,5816096412,NDC,415,EAPG,,outpatient,facility,1,UN,1250.83,1250.83,86.56,126.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.9,,,fee schedule,,,86.56,,,fee schedule,,,112.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.56,,,fee schedule,,,86.56,,,fee schedule,,,86.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,86.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TDAP VACCINE 7 YRS/> IM,2500000345,CDM,636,RC,90715,CPT,,,,,,inpatient,facility,0.5,UN,165.53,165.53,13.24,165.53,,,,,,,,,,,,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.98,,,percent of total billed charges,,,,,,,,,165.53,,,percent of total billed charges,,,91.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,165.53,,,percent of total billed charges,,,86.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.24,,,percent of total billed charges,,,165.53,,,percent of total billed charges,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.24,,,percent of total billed charges,,
TDAP VACCINE 7 YRS/> IM,2500000345,CDM,636,RC,90715,CPT,,,,,,outpatient,facility,0.5,UN,165.53,165.53,13.24,618.77,,96.67,,,percent of total billed charges,,,32.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,165.53,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,60.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,148.98,,,percent of total billed charges,,,,,,,,,165.53,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,86.31,,,percent of total billed charges,,,165.53,,,percent of total billed charges,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.8,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,85.73,,,percent of total billed charges,,,,,,,,,,,,,,,33.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,165.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,165.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.24,,,percent of total billed charges,,,165.53,,,percent of total billed charges,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,165.53,,,percent of total billed charges,,,165.53,,,percent of total billed charges,,,,,,,,,165.53,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,39.73,,,fee schedule,,,165.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,165.53,,,percent of total billed charges,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,116.24,,,percent of total billed charges,,
TDAP VACCINE 7 YRS/> IM,2500000345,CDM,636,RC,90715,CPT,414,EAPG,,,,outpatient,facility,0.5,UN,165.53,165.53,23.83,34.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.93,,,fee schedule,,,23.83,,,fee schedule,,,31.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADENOSINE IV TX 6 MG,2500000410,CDM,636,RC,J0153,HCPCS,1747854202,NDC,,,,inpatient,facility,2,UN,24.55,24.55,1.96,24.55,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.1,,,percent of total billed charges,,,,,,,,,24.55,,,percent of total billed charges,,,13.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,12.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.24,,,percent of total billed charges,,
ADENOSINE IV TX 6 MG,2500000410,CDM,636,RC,J0153,HCPCS,1747854202,NDC,,,,outpatient,facility,2,UN,24.55,24.55,0.44,618.77,,14.34,,,percent of total billed charges,,,4.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,24.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22.1,,,percent of total billed charges,,,,,,,,,24.55,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.8,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.66,,,percent of total billed charges,,,9.3,,,percent of total billed charges,,,12.71,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,24.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.96,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,24.55,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.44,,,fee schedule,,,24.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.24,,,percent of total billed charges,,
ADENOSINE IV TX 6 MG,2500000410,CDM,636,RC,J0153,HCPCS,1747854202,NDC,435,EAPG,,outpatient,facility,2,UN,24.55,24.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPINEPHRINE INJ 1 MG/1 ML,2500000420,CDM,636,RC,J0171,HCPCS,5428810310,NDC,,,,inpatient,facility,1,ML,57.75,57.75,4.62,57.75,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.98,,,percent of total billed charges,,,,,,,,,57.75,,,percent of total billed charges,,,31.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,30.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.55,,,percent of total billed charges,,
EPINEPHRINE INJ 1 MG/1 ML,2500000420,CDM,636,RC,J0171,HCPCS,5428810310,NDC,,,,outpatient,facility,1,ML,57.75,57.75,0.84,618.77,,33.73,,,percent of total billed charges,,,11.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,57.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,21.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,51.98,,,percent of total billed charges,,,,,,,,,57.75,,,percent of total billed charges,,,39.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.11,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,21.88,,,percent of total billed charges,,,29.91,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,57.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,57.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.62,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,,,,,,,57.75,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.84,,,fee schedule,,,57.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,57.75,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,40.55,,,percent of total billed charges,,
EPINEPHRINE INJ 1 MG/1 ML,2500000420,CDM,636,RC,J0171,HCPCS,5428810310,NDC,496,EAPG,,outpatient,facility,1,ML,57.75,57.75,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPINEPHRINE INJ 1 MG/10 ML,2500000422,CDM,636,RC,J0171,HCPCS,7632933161,NDC,,,,inpatient,facility,10,ML,28.88,28.88,2.31,28.88,,,,,,,,,,,,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.99,,,percent of total billed charges,,,,,,,,,28.88,,,percent of total billed charges,,,15.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,28.88,,,percent of total billed charges,,,15.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.28,,,percent of total billed charges,,
EPINEPHRINE INJ 1 MG/10 ML,2500000422,CDM,636,RC,J0171,HCPCS,7632933161,NDC,,,,outpatient,facility,10,ML,28.88,28.88,0.84,618.77,,16.87,,,percent of total billed charges,,,5.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,28.88,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,25.99,,,percent of total billed charges,,,,,,,,,28.88,,,percent of total billed charges,,,19.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.06,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,10.94,,,percent of total billed charges,,,14.96,,,percent of total billed charges,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,28.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.31,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,28.88,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,,,,,,,28.88,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.84,,,fee schedule,,,28.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,28.88,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.28,,,percent of total billed charges,,
EPINEPHRINE INJ 1 MG/10 ML,2500000422,CDM,636,RC,J0171,HCPCS,7632933161,NDC,496,EAPG,,outpatient,facility,10,ML,28.88,28.88,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPICILLIN INJ 500MG,2500000500,CDM,636,RC,J0290,HCPCS,409371801,NDC,,,,inpatient,facility,5,UN,7.72,7.72,0.62,7.72,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.95,,,percent of total billed charges,,,,,,,,,7.72,,,percent of total billed charges,,,4.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.42,,,percent of total billed charges,,
AMPICILLIN INJ 500MG,2500000500,CDM,636,RC,J0290,HCPCS,409371801,NDC,,,,outpatient,facility,5,UN,7.72,7.72,0.62,618.77,,4.51,,,percent of total billed charges,,,1.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.72,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.95,,,percent of total billed charges,,,,,,,,,7.72,,,percent of total billed charges,,,5.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,4,,,percent of total billed charges,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,7.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.62,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,,,,,,,7.72,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.91,,,fee schedule,,,7.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.72,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.86,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.42,,,percent of total billed charges,,
AMPICILLIN INJ 500MG,2500000500,CDM,636,RC,J0290,HCPCS,409371801,NDC,496,EAPG,,outpatient,facility,5,UN,7.72,7.72,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPICILLIN INJ 1 GM,2500000502,CDM,636,RC,J0290,HCPCS,5515011310,NDC,,,,inpatient,facility,1,UN,27.09,27.09,2.17,27.09,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.38,,,percent of total billed charges,,,,,,,,,27.09,,,percent of total billed charges,,,15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,27.09,,,percent of total billed charges,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,
AMPICILLIN INJ 1 GM,2500000502,CDM,636,RC,J0290,HCPCS,5515011310,NDC,,,,outpatient,facility,1,UN,27.09,27.09,0.91,618.77,,15.82,,,percent of total billed charges,,,5.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,27.09,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,24.38,,,percent of total billed charges,,,,,,,,,27.09,,,percent of total billed charges,,,18.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,27.09,,,percent of total billed charges,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.59,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,14.03,,,percent of total billed charges,,,,,,,,,,,,,,,5.42,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,27.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.17,,,percent of total billed charges,,,27.09,,,percent of total billed charges,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,27.09,,,percent of total billed charges,,,,,,,,,27.09,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.91,,,fee schedule,,,27.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,27.09,,,percent of total billed charges,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,19.02,,,percent of total billed charges,,
AMPICILLIN INJ 1 GM,2500000502,CDM,636,RC,J0290,HCPCS,5515011310,NDC,496,EAPG,,outpatient,facility,1,UN,27.09,27.09,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPICILLIN INJ 2 GM,2500000504,CDM,636,RC,J0290,HCPCS,6745735210,NDC,,,,inpatient,facility,2,UN,52.54,52.54,4.2,52.54,,,,,,,,,,,,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.29,,,percent of total billed charges,,,,,,,,,52.54,,,percent of total billed charges,,,29.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,52.54,,,percent of total billed charges,,,27.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.2,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.89,,,percent of total billed charges,,
AMPICILLIN INJ 2 GM,2500000504,CDM,636,RC,J0290,HCPCS,6745735210,NDC,,,,outpatient,facility,2,UN,52.54,52.54,0.91,618.77,,30.68,,,percent of total billed charges,,,10.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,52.54,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,19.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,47.29,,,percent of total billed charges,,,,,,,,,52.54,,,percent of total billed charges,,,35.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.39,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.93,,,percent of total billed charges,,,19.9,,,percent of total billed charges,,,27.21,,,percent of total billed charges,,,,,,,,,,,,,,,10.51,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,52.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,52.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.2,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,52.54,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,,,,,,,52.54,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.91,,,fee schedule,,,52.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,52.54,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,36.89,,,percent of total billed charges,,
AMPICILLIN INJ 2 GM,2500000504,CDM,636,RC,J0290,HCPCS,6745735210,NDC,496,EAPG,,outpatient,facility,2,UN,52.54,52.54,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPICILLIN/SULBACTAM 1.5 GM,2500000510,CDM,636,RC,J0295,HCPCS,4456721010,NDC,,,,inpatient,facility,1.5,UN,31.48,31.48,2.52,31.48,,,,,,,,,,,,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.33,,,percent of total billed charges,,,,,,,,,31.48,,,percent of total billed charges,,,17.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,31.48,,,percent of total billed charges,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,31.48,,,percent of total billed charges,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,
AMPICILLIN/SULBACTAM 1.5 GM,2500000510,CDM,636,RC,J0295,HCPCS,4456721010,NDC,,,,outpatient,facility,1.5,UN,31.48,31.48,2.01,618.77,,18.38,,,percent of total billed charges,,,6.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,31.48,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,28.33,,,percent of total billed charges,,,,,,,,,31.48,,,percent of total billed charges,,,21.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.41,,,percent of total billed charges,,,31.48,,,percent of total billed charges,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.92,,,percent of total billed charges,,,11.92,,,percent of total billed charges,,,16.3,,,percent of total billed charges,,,,,,,,,,,,,,,6.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,31.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.52,,,percent of total billed charges,,,31.48,,,percent of total billed charges,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,31.48,,,percent of total billed charges,,,31.48,,,percent of total billed charges,,,,,,,,,31.48,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.01,,,fee schedule,,,31.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,31.48,,,percent of total billed charges,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,22.11,,,percent of total billed charges,,
AMPICILLIN/SULBACTAM 1.5 GM,2500000510,CDM,636,RC,J0295,HCPCS,4456721010,NDC,496,EAPG,,outpatient,facility,1.5,UN,31.48,31.48,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPICILLIN/SULBACTAM  3 GM,2500000512,CDM,636,RC,J0295,HCPCS,5515011720,NDC,,,,inpatient,facility,3,UN,48.18,48.18,3.85,48.18,,,,,,,,,,,,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.36,,,percent of total billed charges,,,,,,,,,48.18,,,percent of total billed charges,,,26.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,48.18,,,percent of total billed charges,,,25.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.83,,,percent of total billed charges,,
AMPICILLIN/SULBACTAM  3 GM,2500000512,CDM,636,RC,J0295,HCPCS,5515011720,NDC,,,,outpatient,facility,3,UN,48.18,48.18,2.01,618.77,,28.14,,,percent of total billed charges,,,9.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,48.18,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,43.36,,,percent of total billed charges,,,,,,,,,48.18,,,percent of total billed charges,,,32.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.12,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.62,,,percent of total billed charges,,,18.25,,,percent of total billed charges,,,24.95,,,percent of total billed charges,,,,,,,,,,,,,,,9.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,48.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,48.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.85,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,48.18,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,,,,,,,48.18,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.01,,,fee schedule,,,48.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,48.18,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,33.83,,,percent of total billed charges,,
AMPICILLIN/SULBACTAM  3 GM,2500000512,CDM,636,RC,J0295,HCPCS,5515011720,NDC,496,EAPG,,outpatient,facility,3,UN,48.18,48.18,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUCCINYLCHOLINE INJ 200 MG,2500000532,CDM,636,RC,J0330,HCPCS,409662902,NDC,,,,inpatient,facility,10,ML,63.92,63.92,5.11,63.92,,,,,,,,,,,,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.53,,,percent of total billed charges,,,,,,,,,63.92,,,percent of total billed charges,,,35.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,63.92,,,percent of total billed charges,,,33.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.11,,,percent of total billed charges,,,63.92,,,percent of total billed charges,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.88,,,percent of total billed charges,,
SUCCINYLCHOLINE INJ 200 MG,2500000532,CDM,636,RC,J0330,HCPCS,409662902,NDC,,,,outpatient,facility,10,ML,63.92,63.92,0.85,618.77,,37.33,,,percent of total billed charges,,,12.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,63.92,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,23.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,57.53,,,percent of total billed charges,,,,,,,,,63.92,,,percent of total billed charges,,,43.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.33,,,percent of total billed charges,,,63.92,,,percent of total billed charges,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.58,,,percent of total billed charges,,,24.21,,,percent of total billed charges,,,33.1,,,percent of total billed charges,,,,,,,,,,,,,,,12.78,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,63.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,63.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.11,,,percent of total billed charges,,,63.92,,,percent of total billed charges,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,63.92,,,percent of total billed charges,,,63.92,,,percent of total billed charges,,,,,,,,,63.92,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,63.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,63.92,,,percent of total billed charges,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,44.88,,,percent of total billed charges,,
SUCCINYLCHOLINE INJ 200 MG,2500000532,CDM,636,RC,J0330,HCPCS,409662902,NDC,999,EAPG,,outpatient,facility,10,ML,63.92,63.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUCCINYLCHOLINE 20 MG/ML 5 ML,2500000533,CDM,636,RC,J0330,HCPCS,641623401,NDC,,,,inpatient,facility,5,ML,70.26,70.26,5.62,70.26,,,,,,,,,,,,,,70.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.23,,,percent of total billed charges,,,,,,,,,70.26,,,percent of total billed charges,,,38.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.26,,,percent of total billed charges,,,,,,,,,,,,,,,70.26,,,percent of total billed charges,,,36.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.62,,,percent of total billed charges,,,70.26,,,percent of total billed charges,,,70.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.34,,,percent of total billed charges,,
SUCCINYLCHOLINE 20 MG/ML 5 ML,2500000533,CDM,636,RC,J0330,HCPCS,641623401,NDC,,,,outpatient,facility,5,ML,70.26,70.26,0.85,618.77,,41.03,,,percent of total billed charges,,,13.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,70.26,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,70.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,25.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,63.23,,,percent of total billed charges,,,,,,,,,70.26,,,percent of total billed charges,,,47.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,70.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.63,,,percent of total billed charges,,,70.26,,,percent of total billed charges,,,70.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.4,,,percent of total billed charges,,,26.61,,,percent of total billed charges,,,36.39,,,percent of total billed charges,,,,,,,,,,,,,,,14.05,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,70.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,70.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.62,,,percent of total billed charges,,,70.26,,,percent of total billed charges,,,70.26,,,percent of total billed charges,,,,,,,,,,,,,,,70.26,,,percent of total billed charges,,,70.26,,,percent of total billed charges,,,,,,,,,70.26,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,70.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,70.26,,,percent of total billed charges,,,70.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,49.34,,,percent of total billed charges,,
SUCCINYLCHOLINE 20 MG/ML 5 ML,2500000533,CDM,636,RC,J0330,HCPCS,641623401,NDC,999,EAPG,,outpatient,facility,5,ML,70.26,70.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDRALAZINE HCL INJ 20 MG,2500000560,CDM,636,RC,J0360,HCPCS,6332361401,NDC,,,,inpatient,facility,1,ML,47.26,47.26,3.78,47.26,,,,,,,,,,,,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.53,,,percent of total billed charges,,,,,,,,,47.26,,,percent of total billed charges,,,26.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,47.26,,,percent of total billed charges,,,24.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.78,,,percent of total billed charges,,,47.26,,,percent of total billed charges,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.19,,,percent of total billed charges,,
HYDRALAZINE HCL INJ 20 MG,2500000560,CDM,636,RC,J0360,HCPCS,6332361401,NDC,,,,outpatient,facility,1,ML,47.26,47.26,3.78,618.77,,27.6,,,percent of total billed charges,,,9.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,47.26,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,42.53,,,percent of total billed charges,,,,,,,,,47.26,,,percent of total billed charges,,,32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.64,,,percent of total billed charges,,,47.26,,,percent of total billed charges,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.92,,,percent of total billed charges,,,17.9,,,percent of total billed charges,,,24.48,,,percent of total billed charges,,,,,,,,,,,,,,,9.45,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,47.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,47.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.78,,,percent of total billed charges,,,47.26,,,percent of total billed charges,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,47.26,,,percent of total billed charges,,,47.26,,,percent of total billed charges,,,,,,,,,47.26,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.27,,,fee schedule,,,47.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,47.26,,,percent of total billed charges,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,33.19,,,percent of total billed charges,,
HYDRALAZINE HCL INJ 20 MG,2500000560,CDM,636,RC,J0360,HCPCS,6332361401,NDC,999,EAPG,,outpatient,facility,1,ML,47.26,47.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATROPINE SULF INJ 1 MG/10 ML,2500000607,CDM,636,RC,J0461,HCPCS,7632933401,NDC,,,,inpatient,facility,10,UN,37.79,37.79,3.02,37.79,,,,,,,,,,,,,,37.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,,,,37.79,,,percent of total billed charges,,,20.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.79,,,percent of total billed charges,,,,,,,,,,,,,,,37.79,,,percent of total billed charges,,,19.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.02,,,percent of total billed charges,,,37.79,,,percent of total billed charges,,,37.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.54,,,percent of total billed charges,,
ATROPINE SULF INJ 1 MG/10 ML,2500000607,CDM,636,RC,J0461,HCPCS,7632933401,NDC,,,,outpatient,facility,10,UN,37.79,37.79,0.09,618.77,,22.07,,,percent of total billed charges,,,7.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,37.79,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,37.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,13.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,34.01,,,percent of total billed charges,,,,,,,,,37.79,,,percent of total billed charges,,,25.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,37.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.7,,,percent of total billed charges,,,37.79,,,percent of total billed charges,,,37.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.72,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,19.57,,,percent of total billed charges,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,37.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,37.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.02,,,percent of total billed charges,,,37.79,,,percent of total billed charges,,,37.79,,,percent of total billed charges,,,,,,,,,,,,,,,37.79,,,percent of total billed charges,,,37.79,,,percent of total billed charges,,,,,,,,,37.79,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,37.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,37.79,,,percent of total billed charges,,,37.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,26.54,,,percent of total billed charges,,
ATROPINE SULF INJ 1 MG/10 ML,2500000607,CDM,636,RC,J0461,HCPCS,7632933401,NDC,496,EAPG,,outpatient,facility,10,UN,37.79,37.79,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DICYCLOMINE HCL INJ 20 MG,2500000630,CDM,636,RC,J0500,HCPCS,7226612705,NDC,,,,inpatient,facility,2,ML,81.18,81.18,6.49,81.18,,,,,,,,,,,,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.06,,,percent of total billed charges,,,,,,,,,81.18,,,percent of total billed charges,,,44.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,81.18,,,percent of total billed charges,,,42.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.49,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57,,,percent of total billed charges,,
DICYCLOMINE HCL INJ 20 MG,2500000630,CDM,636,RC,J0500,HCPCS,7226612705,NDC,,,,outpatient,facility,2,ML,81.18,81.18,6.49,618.77,,47.41,,,percent of total billed charges,,,15.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,81.18,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,29.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,73.06,,,percent of total billed charges,,,,,,,,,81.18,,,percent of total billed charges,,,54.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.33,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.7,,,percent of total billed charges,,,30.75,,,percent of total billed charges,,,42.04,,,percent of total billed charges,,,,,,,,,,,,,,,16.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,81.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,81.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.49,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,81.18,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,,,,,,,81.18,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,21.1,,,fee schedule,,,81.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,81.18,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,57,,,percent of total billed charges,,
DICYCLOMINE HCL INJ 20 MG,2500000630,CDM,636,RC,J0500,HCPCS,7226612705,NDC,999,EAPG,,outpatient,facility,2,ML,81.18,81.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZTROPINE MESY INJ 2 MG,2500000642,CDM,636,RC,J0515,HCPCS,143972905,NDC,,,,inpatient,facility,2,UN,198,198,15.84,198,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,,,,,,,198,,,percent of total billed charges,,,109.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,103.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.04,,,percent of total billed charges,,
BENZTROPINE MESY INJ 2 MG,2500000642,CDM,636,RC,J0515,HCPCS,143972905,NDC,,,,outpatient,facility,2,UN,198,198,15.84,618.77,,115.63,,,percent of total billed charges,,,38.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,198,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,72.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,178.2,,,percent of total billed charges,,,,,,,,,198,,,percent of total billed charges,,,134.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.24,,,percent of total billed charges,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.48,,,percent of total billed charges,,,75,,,percent of total billed charges,,,102.54,,,percent of total billed charges,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,198,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,198,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.84,,,percent of total billed charges,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,198,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,16.91,,,fee schedule,,,198,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,139.04,,,percent of total billed charges,,
BENZTROPINE MESY INJ 2 MG,2500000642,CDM,636,RC,J0515,HCPCS,143972905,NDC,999,EAPG,,outpatient,facility,2,UN,198,198,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PENICILLIN G BENZ 1200000 U,2500000710,CDM,636,RC,J0561,HCPCS,6079370110,NDC,,,,inpatient,facility,2,ML,1006.46,1006.46,80.52,1006.46,,,,,,,,,,,,,,1006.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,905.81,,,percent of total billed charges,,,,,,,,,1006.46,,,percent of total billed charges,,,557.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,918.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1006.46,,,percent of total billed charges,,,,,,,,,,,,,,,1006.46,,,percent of total billed charges,,,524.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.52,,,percent of total billed charges,,,1006.46,,,percent of total billed charges,,,1006.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1006.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,706.74,,,percent of total billed charges,,
PENICILLIN G BENZ 1200000 U,2500000710,CDM,636,RC,J0561,HCPCS,6079370110,NDC,,,,outpatient,facility,2,ML,1006.46,1006.46,11.42,1006.46,,587.77,,,percent of total billed charges,,,,,,,,,1006.46,,,percent of total billed charges,,,28.33,,,fee schedule,,,27.3,,,fee schedule,,,,,,,,,27.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1006.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,905.81,,,percent of total billed charges,,,,,,,,,1006.46,,,percent of total billed charges,,,681.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,772.96,,,percent of total billed charges,,,,,,,,,,,,,,,21.73,,,fee schedule,,,21.73,,,fee schedule,,,,,,,,,618.77,,,per diem,,,1006.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,524.77,,,percent of total billed charges,,,1006.46,,,percent of total billed charges,,,1006.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,764.91,,,percent of total billed charges,,,381.25,,,percent of total billed charges,,,521.25,,,percent of total billed charges,,,,,,,,,,,,,,,201.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,36.92,,,fee schedule,,,16.46,,,fee schedule,,,,,,,,,,,,,,,80.52,,,percent of total billed charges,,,1006.46,,,percent of total billed charges,,,1006.46,,,percent of total billed charges,,,,,,,,,,,,,,,1006.46,,,percent of total billed charges,,,1006.46,,,percent of total billed charges,,,,,,,,,1006.46,,,fee schedule,,,17.57,,,fee schedule,,,,,,,,,,,,,,,15.45,,,fee schedule,,,20.6,,,fee schedule,,,11.42,,,fee schedule,,,24.88,,,fee schedule,,,1006.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1006.46,,,percent of total billed charges,,,1006.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,706.74,,,percent of total billed charges,,
PENICILLIN G BENZ 1200000 U,2500000710,CDM,636,RC,J0561,HCPCS,6079370110,NDC,1829,APC,,outpatient,facility,2,ML,1006.46,1006.46,24.37,368.36,,,,,,,,27.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,26.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.09,,,fee schedule,,,,,,,,,368.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,26.82,,,fee schedule,,,,,,,,,,,,,,,26.82,,,fee schedule,,,28.16,,,fee schedule,,,,,,,,,26.82,,,fee schedule,,,26.82,,,fee schedule,,,28.16,,,fee schedule,,,,,,,,,,,,,,,38.89,,,fee schedule,,,,,,,,,,,,,,,26.82,,,fee schedule,,,,,,,,,,,,,,,25.75,,,fee schedule,,,28.7,,,fee schedule,,,28.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.82,,,fee schedule,,,26.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,26.82,,,fee schedule,,,26.82,,,fee schedule,,,,,,,,,,,,,,,26.82,,,fee schedule,,,,,,,,,,,,,,,26.82,,,fee schedule,,,27.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.37,,,fee schedule,,,26.82,,,fee schedule,,,27.89,,,fee schedule,,,26.82,,,fee schedule,,,,,,,,,26.82,,,fee schedule,,,,,,,,,26.82,,,fee schedule,,,,,,,,
PENICILLIN G BENZ 1200000 U,2500000710,CDM,636,RC,J0561,HCPCS,6079370110,NDC,436,EAPG,,outpatient,facility,2,ML,1006.46,1006.46,126.95,186.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.11,,,fee schedule,,,126.95,,,fee schedule,,,165.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOTULINUM TOXIN A 100 UNITS,2500000732,CDM,636,RC,J0585,HCPCS,23114501,NDC,,,,inpatient,facility,100,UN,2842.4,2842.4,227.39,2842.4,,,,,,,,,,,,,,2842.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2558.16,,,percent of total billed charges,,,,,,,,,2842.4,,,percent of total billed charges,,,1573.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2593.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2842.4,,,percent of total billed charges,,,,,,,,,,,,,,,2842.4,,,percent of total billed charges,,,1482.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,568.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.39,,,percent of total billed charges,,,2842.4,,,percent of total billed charges,,,2842.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2842.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1995.93,,,percent of total billed charges,,
BOTULINUM TOXIN A 100 UNITS,2500000732,CDM,636,RC,J0585,HCPCS,23114501,NDC,,,,outpatient,facility,100,UN,2842.4,2842.4,4.25,2842.4,,1659.96,,,percent of total billed charges,,,,,,,,,2842.4,,,percent of total billed charges,,,7.54,,,fee schedule,,,7.27,,,fee schedule,,,,,,,,,7.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2842.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2558.16,,,percent of total billed charges,,,,,,,,,2842.4,,,percent of total billed charges,,,1924.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2182.96,,,percent of total billed charges,,,,,,,,,,,,,,,6.33,,,fee schedule,,,6.33,,,fee schedule,,,,,,,,,618.77,,,per diem,,,2842.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1482.03,,,percent of total billed charges,,,2842.4,,,percent of total billed charges,,,2842.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2160.22,,,percent of total billed charges,,,1076.7,,,percent of total billed charges,,,1472.08,,,percent of total billed charges,,,,,,,,,,,,,,,568.48,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,13.75,,,fee schedule,,,6.13,,,fee schedule,,,,,,,,,,,,,,,227.39,,,percent of total billed charges,,,2842.4,,,percent of total billed charges,,,2842.4,,,percent of total billed charges,,,,,,,,,,,,,,,2842.4,,,percent of total billed charges,,,2842.4,,,percent of total billed charges,,,,,,,,,2842.4,,,fee schedule,,,6.54,,,fee schedule,,,,,,,,,,,,,,,5.75,,,fee schedule,,,7.67,,,fee schedule,,,4.25,,,fee schedule,,,6.61,,,fee schedule,,,2842.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2842.4,,,percent of total billed charges,,,2842.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1421.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1995.93,,,percent of total billed charges,,
BOTULINUM TOXIN A 100 UNITS,2500000732,CDM,636,RC,J0585,HCPCS,23114501,NDC,902,APC,,outpatient,facility,100,UN,2842.4,2842.4,6.21,1040.32,,,,,,,,6.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.53,,,fee schedule,,,,,,,,,1040.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,6.47,,,fee schedule,,,,,,,,,,,,,,,6.47,,,fee schedule,,,6.79,,,fee schedule,,,,,,,,,6.47,,,fee schedule,,,6.47,,,fee schedule,,,6.79,,,fee schedule,,,,,,,,,,,,,,,9.38,,,fee schedule,,,,,,,,,,,,,,,6.47,,,fee schedule,,,,,,,,,,,,,,,6.21,,,fee schedule,,,6.92,,,fee schedule,,,6.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.47,,,fee schedule,,,6.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.47,,,fee schedule,,,6.47,,,fee schedule,,,,,,,,,,,,,,,6.47,,,fee schedule,,,,,,,,,,,,,,,6.47,,,fee schedule,,,6.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.41,,,fee schedule,,,6.47,,,fee schedule,,,6.73,,,fee schedule,,,6.47,,,fee schedule,,,,,,,,,6.47,,,fee schedule,,,,,,,,,6.47,,,fee schedule,,,,,,,,
BOTULINUM TOXIN A 100 UNITS,2500000732,CDM,636,RC,J0585,HCPCS,23114501,NDC,439,EAPG,,outpatient,facility,100,UN,2842.4,2842.4,767.47,1125.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.11,,,fee schedule,,,767.47,,,fee schedule,,,1000.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,767.47,,,fee schedule,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCIUM GLUCONATE 10 ML INJ,2500000760,CDM,250,RC,J0613,HCPCS,6332336019,NDC,,,,inpatient,facility,10,UN,33.07,33.07,2.65,33.07,,,,,,,,,,,,,,33.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.76,,,percent of total billed charges,,,,,,,,,33.07,,,percent of total billed charges,,,18.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.07,,,percent of total billed charges,,,,,,,,,,,,,,,33.07,,,percent of total billed charges,,,17.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,33.07,,,percent of total billed charges,,,33.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.22,,,percent of total billed charges,,
CALCIUM GLUCONATE 10 ML INJ,2500000760,CDM,250,RC,J0613,HCPCS,6332336019,NDC,,,,outpatient,facility,10,UN,33.07,33.07,0.09,618.77,,19.31,,,percent of total billed charges,,,6.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,33.07,,,percent of total billed charges,,,0.11,,,fee schedule,,,0.1,,,fee schedule,,,,,,,,,0.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,33.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,12.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,29.76,,,percent of total billed charges,,,,,,,,,33.07,,,percent of total billed charges,,,22.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,33.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.24,,,percent of total billed charges,,,33.07,,,percent of total billed charges,,,33.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.13,,,percent of total billed charges,,,12.53,,,percent of total billed charges,,,17.13,,,percent of total billed charges,,,,,,,,,,,,,,,6.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,33.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.65,,,percent of total billed charges,,,33.07,,,percent of total billed charges,,,33.07,,,percent of total billed charges,,,,,,,,,,,,,,,33.07,,,percent of total billed charges,,,33.07,,,percent of total billed charges,,,,,,,,,33.07,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,33.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,33.07,,,percent of total billed charges,,,33.07,,,percent of total billed charges,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,23.22,,,percent of total billed charges,,
CALCIUM GLUCONATE 10 ML INJ,2500000760,CDM,250,RC,J0613,HCPCS,6332336019,NDC,999,EAPG,,outpatient,facility,10,UN,33.07,33.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCIUM GLUCONATE 50 ML INJ,2500000762,CDM,250,RC,J0613,HCPCS,,,,,,inpatient,facility,1,UN,78.21,78.21,6.26,78.21,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,78.21,,,percent of total billed charges,,,43.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,40.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.92,,,percent of total billed charges,,
CALCIUM GLUCONATE 50 ML INJ,2500000762,CDM,250,RC,J0613,HCPCS,,,,,,outpatient,facility,1,UN,78.21,78.21,0.09,618.77,,45.67,,,percent of total billed charges,,,15.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,78.21,,,percent of total billed charges,,,0.11,,,fee schedule,,,0.1,,,fee schedule,,,,,,,,,0.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,28.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,70.39,,,percent of total billed charges,,,,,,,,,78.21,,,percent of total billed charges,,,52.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.78,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.44,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,40.5,,,percent of total billed charges,,,,,,,,,,,,,,,15.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,78.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,78.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.26,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,,,,,,,78.21,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,78.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,78.21,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,54.92,,,percent of total billed charges,,
CALCIUM GLUCONATE 50 ML INJ,2500000762,CDM,250,RC,J0613,HCPCS,999,EAPG,,,,outpatient,facility,1,UN,78.21,78.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCITONIN SALMON INJ 400 U,2500000780,CDM,636,RC,J0630,HCPCS,6745767502,NDC,,,,inpatient,facility,2,ML,10704.14,10704.14,856.33,10704.14,,,,,,,,,,,,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9633.73,,,percent of total billed charges,,,,,,,,,10704.14,,,percent of total billed charges,,,5925.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9766.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,10704.14,,,percent of total billed charges,,,5581.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2140.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,856.33,,,percent of total billed charges,,,10704.14,,,percent of total billed charges,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7516.45,,,percent of total billed charges,,
CALCITONIN SALMON INJ 400 U,2500000780,CDM,636,RC,J0630,HCPCS,6745767502,NDC,,,,outpatient,facility,2,ML,10704.14,10704.14,319.69,10704.14,,6251.22,,,percent of total billed charges,,,,,,,,,10704.14,,,percent of total billed charges,,,1267.07,,,fee schedule,,,1220.97,,,fee schedule,,,,,,,,,1220.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9633.73,,,percent of total billed charges,,,,,,,,,10704.14,,,percent of total billed charges,,,7248.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8220.78,,,percent of total billed charges,,,,,,,,,,,,,,,1069.5,,,fee schedule,,,1069.5,,,fee schedule,,,,,,,,,618.77,,,per diem,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5581.14,,,percent of total billed charges,,,10704.14,,,percent of total billed charges,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8135.15,,,percent of total billed charges,,,4054.73,,,percent of total billed charges,,,5543.67,,,percent of total billed charges,,,,,,,,,,,,,,,2140.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3922.59,,,fee schedule,,,1748.9,,,fee schedule,,,,,,,,,,,,,,,856.33,,,percent of total billed charges,,,10704.14,,,percent of total billed charges,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,10704.14,,,percent of total billed charges,,,10704.14,,,percent of total billed charges,,,,,,,,,10704.14,,,fee schedule,,,1866.21,,,fee schedule,,,,,,,,,,,,,,,1641.06,,,fee schedule,,,2188.08,,,fee schedule,,,1213.04,,,fee schedule,,,1112.42,,,fee schedule,,,10704.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10704.14,,,percent of total billed charges,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5352.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7516.45,,,percent of total billed charges,,
CALCITONIN SALMON INJ 400 U,2500000780,CDM,636,RC,J0630,HCPCS,6745767502,NDC,1433,APC,,outpatient,facility,2,ML,10704.14,10704.14,1096.71,3917.72,,,,,,,,1176.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1142.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1153.83,,,fee schedule,,,,,,,,,3917.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1142.41,,,fee schedule,,,,,,,,,,,,,,,1142.41,,,fee schedule,,,1199.53,,,fee schedule,,,,,,,,,1142.41,,,fee schedule,,,1142.41,,,fee schedule,,,1199.53,,,fee schedule,,,,,,,,,,,,,,,1656.49,,,fee schedule,,,,,,,,,,,,,,,1142.41,,,fee schedule,,,,,,,,,,,,,,,1096.71,,,fee schedule,,,1222.38,,,fee schedule,,,1199.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1142.41,,,fee schedule,,,1142.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1188.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1428.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1428.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1142.41,,,fee schedule,,,1142.41,,,fee schedule,,,,,,,,,,,,,,,1142.41,,,fee schedule,,,,,,,,,,,,,,,1142.41,,,fee schedule,,,1176.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1173.06,,,fee schedule,,,1142.41,,,fee schedule,,,1188.11,,,fee schedule,,,1142.41,,,fee schedule,,,,,,,,,1142.41,,,fee schedule,,,,,,,,,1142.41,,,fee schedule,,,,,,,,
CALCITONIN SALMON INJ 400 U,2500000780,CDM,636,RC,J0630,HCPCS,6745767502,NDC,999,EAPG,,outpatient,facility,2,ML,10704.14,10704.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCITONIN NASL 200IU ACT3.7ML,2500000785,CDM,637,RC,4988416111,NDC,,,,,,inpatient,facility,3.7,UN,391.18,391.18,31.29,391.18,,,,,,,,,,,,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.06,,,percent of total billed charges,,,,,,,,,391.18,,,percent of total billed charges,,,216.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,356.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,391.18,,,percent of total billed charges,,,203.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.29,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.69,,,percent of total billed charges,,
CALCITONIN NASL 200IU ACT3.7ML,2500000785,CDM,637,RC,4988416111,NDC,,,,,,outpatient,facility,3.7,UN,391.18,391.18,31.29,618.77,,228.45,,,percent of total billed charges,,,76.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,391.18,,,percent of total billed charges,,,344.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,344.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,344.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,143.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,352.06,,,percent of total billed charges,,,,,,,,,391.18,,,percent of total billed charges,,,264.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,300.43,,,percent of total billed charges,,,,,,,,,,,,,,,211.24,,,percent of total billed charges,,,211.24,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,203.96,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,297.3,,,percent of total billed charges,,,148.18,,,percent of total billed charges,,,202.59,,,percent of total billed charges,,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,144.74,,,percent of total billed charges,,,144.74,,,percent of total billed charges,,,391.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,391.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.29,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,391.18,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,,,,,,,391.18,,,fee schedule,,,363.88,,,percent of total billed charges,,,,,,,,,,,,,,,363.88,,,percent of total billed charges,,,363.88,,,percent of total billed charges,,,363.88,,,percent of total billed charges,,,293.38,,,percent of total billed charges,,,391.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,391.18,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,274.69,,,percent of total billed charges,,
CALCITONIN NASL 200IU ACT3.7ML,2500000785,CDM,637,RC,4988416111,NDC,999,EAPG,,,,outpatient,facility,3.7,UN,391.18,391.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFAZOLIN  SOD INJ  500  MG,2500000822,CDM,636,RC,J0690,HCPCS,4456770625,NDC,,,,inpatient,facility,500,GR,6.34,6.34,0.51,6.34,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.71,,,percent of total billed charges,,,,,,,,,6.34,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,
CEFAZOLIN  SOD INJ  500  MG,2500000822,CDM,636,RC,J0690,HCPCS,4456770625,NDC,,,,outpatient,facility,500,GR,6.34,6.34,0.51,618.77,,3.7,,,percent of total billed charges,,,1.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.34,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.71,,,percent of total billed charges,,,,,,,,,6.34,,,percent of total billed charges,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.82,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,6.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.51,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,6.34,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,6.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.45,,,percent of total billed charges,,
CEFAZOLIN  SOD INJ  500  MG,2500000822,CDM,636,RC,J0690,HCPCS,4456770625,NDC,496,EAPG,,outpatient,facility,500,GR,6.34,6.34,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFAZOLIN  SOD 1 GM INJ,2500000824,CDM,636,RC,J0690,HCPCS,6050561425,NDC,,,,inpatient,facility,100,GR,8.61,8.61,0.69,8.61,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.75,,,percent of total billed charges,,,,,,,,,8.61,,,percent of total billed charges,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,4.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.05,,,percent of total billed charges,,
CEFAZOLIN  SOD 1 GM INJ,2500000824,CDM,636,RC,J0690,HCPCS,6050561425,NDC,,,,outpatient,facility,100,GR,8.61,8.61,0.69,618.77,,5.03,,,percent of total billed charges,,,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.61,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.75,,,percent of total billed charges,,,,,,,,,8.61,,,percent of total billed charges,,,5.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.49,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.54,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,8.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.69,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,8.61,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,8.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.05,,,percent of total billed charges,,
CEFAZOLIN  SOD 1 GM INJ,2500000824,CDM,636,RC,J0690,HCPCS,6050561425,NDC,496,EAPG,,outpatient,facility,100,GR,8.61,8.61,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFAZOLIN 2 GM/50 ML D5W PRMX,2500000827,CDM,636,RC,J0690,HCPCS,264310511,NDC,,,,inpatient,facility,50,GR,38.3,38.3,3.06,38.3,,,,,,,,,,,,,,38.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.47,,,percent of total billed charges,,,,,,,,,38.3,,,percent of total billed charges,,,21.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.3,,,percent of total billed charges,,,,,,,,,,,,,,,38.3,,,percent of total billed charges,,,19.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,38.3,,,percent of total billed charges,,,38.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.89,,,percent of total billed charges,,
CEFAZOLIN 2 GM/50 ML D5W PRMX,2500000827,CDM,636,RC,J0690,HCPCS,264310511,NDC,,,,outpatient,facility,50,GR,38.3,38.3,0.85,618.77,,22.37,,,percent of total billed charges,,,7.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,38.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,38.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,34.47,,,percent of total billed charges,,,,,,,,,38.3,,,percent of total billed charges,,,25.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,38.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.97,,,percent of total billed charges,,,38.3,,,percent of total billed charges,,,38.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.11,,,percent of total billed charges,,,14.51,,,percent of total billed charges,,,19.84,,,percent of total billed charges,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,38.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,38.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.06,,,percent of total billed charges,,,38.3,,,percent of total billed charges,,,38.3,,,percent of total billed charges,,,,,,,,,,,,,,,38.3,,,percent of total billed charges,,,38.3,,,percent of total billed charges,,,,,,,,,38.3,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,38.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,38.3,,,percent of total billed charges,,,38.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,26.89,,,percent of total billed charges,,
CEFAZOLIN 2 GM/50 ML D5W PRMX,2500000827,CDM,636,RC,J0690,HCPCS,264310511,NDC,496,EAPG,,outpatient,facility,50,GR,38.3,38.3,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFAZOLIN 3 GM/100ML NS PRMX,2500000829,CDM,636,RC,J0690,HCPCS,6050561425,NDC,,,,inpatient,facility,100,GR,8.61,8.61,0.69,8.61,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.75,,,percent of total billed charges,,,,,,,,,8.61,,,percent of total billed charges,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,4.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.05,,,percent of total billed charges,,
CEFAZOLIN 3 GM/100ML NS PRMX,2500000829,CDM,636,RC,J0690,HCPCS,6050561425,NDC,,,,outpatient,facility,100,GR,8.61,8.61,0.69,618.77,,5.03,,,percent of total billed charges,,,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.61,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.75,,,percent of total billed charges,,,,,,,,,8.61,,,percent of total billed charges,,,5.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.49,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.54,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,8.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.69,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,8.61,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,8.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.05,,,percent of total billed charges,,
CEFAZOLIN 3 GM/100ML NS PRMX,2500000829,CDM,636,RC,J0690,HCPCS,6050561425,NDC,496,EAPG,,outpatient,facility,100,GR,8.61,8.61,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFOXITIN  SOD INJ 1 GM,2500000830,CDM,636,RC,J0694,HCPCS,6332334125,NDC,,,,inpatient,facility,1,UN,23.07,23.07,1.85,23.07,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.76,,,percent of total billed charges,,,,,,,,,23.07,,,percent of total billed charges,,,12.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,12.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,
CEFOXITIN  SOD INJ 1 GM,2500000830,CDM,636,RC,J0694,HCPCS,6332334125,NDC,,,,outpatient,facility,1,UN,23.07,23.07,1.85,618.77,,13.47,,,percent of total billed charges,,,4.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,23.07,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,20.76,,,percent of total billed charges,,,,,,,,,23.07,,,percent of total billed charges,,,15.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.03,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.53,,,percent of total billed charges,,,8.74,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,4.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,23.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.85,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,,,,,,,23.07,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.65,,,fee schedule,,,23.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,23.07,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,16.2,,,percent of total billed charges,,
CEFOXITIN  SOD INJ 1 GM,2500000830,CDM,636,RC,J0694,HCPCS,6332334125,NDC,496,EAPG,,outpatient,facility,1,UN,23.07,23.07,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFOXITIN  SOD INJ  2 GM,2500000832,CDM,636,RC,J0694,HCPCS,6332334225,NDC,,,,inpatient,facility,2,UN,46.07,46.07,3.69,46.07,,,,,,,,,,,,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.46,,,percent of total billed charges,,,,,,,,,46.07,,,percent of total billed charges,,,25.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,46.07,,,percent of total billed charges,,,24.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.69,,,percent of total billed charges,,,46.07,,,percent of total billed charges,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.35,,,percent of total billed charges,,
CEFOXITIN  SOD INJ  2 GM,2500000832,CDM,636,RC,J0694,HCPCS,6332334225,NDC,,,,outpatient,facility,2,UN,46.07,46.07,3.69,618.77,,26.9,,,percent of total billed charges,,,8.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,46.07,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,41.46,,,percent of total billed charges,,,,,,,,,46.07,,,percent of total billed charges,,,31.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.02,,,percent of total billed charges,,,46.07,,,percent of total billed charges,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,17.45,,,percent of total billed charges,,,23.86,,,percent of total billed charges,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,46.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.69,,,percent of total billed charges,,,46.07,,,percent of total billed charges,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,46.07,,,percent of total billed charges,,,46.07,,,percent of total billed charges,,,,,,,,,46.07,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.65,,,fee schedule,,,46.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,46.07,,,percent of total billed charges,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,32.35,,,percent of total billed charges,,
CEFOXITIN  SOD INJ  2 GM,2500000832,CDM,636,RC,J0694,HCPCS,6332334225,NDC,496,EAPG,,outpatient,facility,2,UN,46.07,46.07,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTRIAXONE  SOD INJ  250 MG,2500000850,CDM,636,RC,J0696,HCPCS,6050561511,NDC,,,,inpatient,facility,250,UN,48.91,48.91,3.91,48.91,,,,,,,,,,,,,,48.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.02,,,percent of total billed charges,,,,,,,,,48.91,,,percent of total billed charges,,,27.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.91,,,percent of total billed charges,,,,,,,,,,,,,,,48.91,,,percent of total billed charges,,,25.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.91,,,percent of total billed charges,,,48.91,,,percent of total billed charges,,,48.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.34,,,percent of total billed charges,,
CEFTRIAXONE  SOD INJ  250 MG,2500000850,CDM,636,RC,J0696,HCPCS,6050561511,NDC,,,,outpatient,facility,250,UN,48.91,48.91,0.47,618.77,,28.56,,,percent of total billed charges,,,9.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,48.91,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,48.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,44.02,,,percent of total billed charges,,,,,,,,,48.91,,,percent of total billed charges,,,33.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,48.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.5,,,percent of total billed charges,,,48.91,,,percent of total billed charges,,,48.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.17,,,percent of total billed charges,,,18.53,,,percent of total billed charges,,,25.33,,,percent of total billed charges,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,48.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,48.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.91,,,percent of total billed charges,,,48.91,,,percent of total billed charges,,,48.91,,,percent of total billed charges,,,,,,,,,,,,,,,48.91,,,percent of total billed charges,,,48.91,,,percent of total billed charges,,,,,,,,,48.91,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.47,,,fee schedule,,,48.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,48.91,,,percent of total billed charges,,,48.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,34.34,,,percent of total billed charges,,
CEFTRIAXONE  SOD INJ  250 MG,2500000850,CDM,636,RC,J0696,HCPCS,6050561511,NDC,496,EAPG,,outpatient,facility,250,UN,48.91,48.91,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTRIAXONE  SOD INJ 500 MG,2500000852,CDM,636,RC,J0696,HCPCS,6050561521,NDC,,,,inpatient,facility,500,UN,88.6,88.6,7.09,88.6,,,,,,,,,,,,,,88.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.74,,,percent of total billed charges,,,,,,,,,88.6,,,percent of total billed charges,,,49.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.6,,,percent of total billed charges,,,,,,,,,,,,,,,88.6,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.09,,,percent of total billed charges,,,88.6,,,percent of total billed charges,,,88.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,88.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.21,,,percent of total billed charges,,
CEFTRIAXONE  SOD INJ 500 MG,2500000852,CDM,636,RC,J0696,HCPCS,6050561521,NDC,,,,outpatient,facility,500,UN,88.6,88.6,0.47,618.77,,51.74,,,percent of total billed charges,,,17.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,88.6,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,88.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,32.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,79.74,,,percent of total billed charges,,,,,,,,,88.6,,,percent of total billed charges,,,60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,88.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,88.6,,,percent of total billed charges,,,88.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.34,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,45.89,,,percent of total billed charges,,,,,,,,,,,,,,,17.72,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,88.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,88.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.09,,,percent of total billed charges,,,88.6,,,percent of total billed charges,,,88.6,,,percent of total billed charges,,,,,,,,,,,,,,,88.6,,,percent of total billed charges,,,88.6,,,percent of total billed charges,,,,,,,,,88.6,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.47,,,fee schedule,,,88.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,88.6,,,percent of total billed charges,,,88.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,62.21,,,percent of total billed charges,,
CEFTRIAXONE  SOD INJ 500 MG,2500000852,CDM,636,RC,J0696,HCPCS,6050561521,NDC,496,EAPG,,outpatient,facility,500,UN,88.6,88.6,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTRIAXONE  SOD  INJ 1GM,2500000854,CDM,636,RC,J0696,HCPCS,4456770125,NDC,,,,inpatient,facility,1,UN,11.88,11.88,0.95,11.88,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.69,,,percent of total billed charges,,,,,,,,,11.88,,,percent of total billed charges,,,6.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,6.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.34,,,percent of total billed charges,,
CEFTRIAXONE  SOD  INJ 1GM,2500000854,CDM,636,RC,J0696,HCPCS,4456770125,NDC,,,,outpatient,facility,1,UN,11.88,11.88,0.47,618.77,,6.94,,,percent of total billed charges,,,2.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.88,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.69,,,percent of total billed charges,,,,,,,,,11.88,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.03,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,6.15,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,11.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.95,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,11.88,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.47,,,fee schedule,,,11.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.34,,,percent of total billed charges,,
CEFTRIAXONE  SOD  INJ 1GM,2500000854,CDM,636,RC,J0696,HCPCS,4456770125,NDC,496,EAPG,,outpatient,facility,1,UN,11.88,11.88,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTRIAXONE  SOD  INJ 2GM,2500000856,CDM,636,RC,J0696,HCPCS,143985625,NDC,,,,inpatient,facility,2,UN,9.9,9.9,0.79,9.9,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,5.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.95,,,percent of total billed charges,,
CEFTRIAXONE  SOD  INJ 2GM,2500000856,CDM,636,RC,J0696,HCPCS,143985625,NDC,,,,outpatient,facility,2,UN,9.9,9.9,0.47,618.77,,5.78,,,percent of total billed charges,,,1.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.9,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.91,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.16,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.52,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,9.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,9.9,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.47,,,fee schedule,,,9.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.95,,,percent of total billed charges,,
CEFTRIAXONE  SOD  INJ 2GM,2500000856,CDM,636,RC,J0696,HCPCS,143985625,NDC,496,EAPG,,outpatient,facility,2,UN,9.9,9.9,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTAROLINE 400 MG INJ,2500000907,CDM,636,RC,J0712,HCPCS,456040010,NDC,,,,inpatient,facility,400,GR,770.62,770.62,61.65,770.62,,,,,,,,,,,,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,693.56,,,percent of total billed charges,,,,,,,,,770.62,,,percent of total billed charges,,,426.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,703.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,770.62,,,percent of total billed charges,,,401.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.65,,,percent of total billed charges,,,770.62,,,percent of total billed charges,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,541.13,,,percent of total billed charges,,
CEFTAROLINE 400 MG INJ,2500000907,CDM,636,RC,J0712,HCPCS,456040010,NDC,,,,outpatient,facility,400,GR,770.62,770.62,2.55,770.62,,450.04,,,percent of total billed charges,,,,,,,,,770.62,,,percent of total billed charges,,,4.76,,,fee schedule,,,4.59,,,fee schedule,,,,,,,,,4.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,693.56,,,percent of total billed charges,,,,,,,,,770.62,,,percent of total billed charges,,,521.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,591.84,,,percent of total billed charges,,,,,,,,,,,,,,,3.84,,,fee schedule,,,3.84,,,fee schedule,,,,,,,,,618.77,,,per diem,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,401.8,,,percent of total billed charges,,,770.62,,,percent of total billed charges,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,585.67,,,percent of total billed charges,,,291.91,,,percent of total billed charges,,,399.1,,,percent of total billed charges,,,,,,,,,,,,,,,154.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.25,,,fee schedule,,,3.68,,,fee schedule,,,,,,,,,,,,,,,61.65,,,percent of total billed charges,,,770.62,,,percent of total billed charges,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,770.62,,,percent of total billed charges,,,770.62,,,percent of total billed charges,,,,,,,,,770.62,,,fee schedule,,,3.93,,,fee schedule,,,,,,,,,,,,,,,3.45,,,fee schedule,,,4.6,,,fee schedule,,,2.55,,,fee schedule,,,4.18,,,fee schedule,,,770.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,770.62,,,percent of total billed charges,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,541.13,,,percent of total billed charges,,
CEFTAROLINE 400 MG INJ,2500000907,CDM,636,RC,J0712,HCPCS,456040010,NDC,1824,APC,,outpatient,facility,400,GR,770.62,770.62,3.79,282.05,,,,,,,,4.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,fee schedule,,,,,,,,,282.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,3.95,,,fee schedule,,,4.15,,,fee schedule,,,,,,,,,3.95,,,fee schedule,,,3.95,,,fee schedule,,,4.15,,,fee schedule,,,,,,,,,,,,,,,5.73,,,fee schedule,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,3.79,,,fee schedule,,,4.23,,,fee schedule,,,4.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,3.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,3.95,,,fee schedule,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,3.95,,,fee schedule,,,4.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.94,,,fee schedule,,,3.95,,,fee schedule,,,4.11,,,fee schedule,,,3.95,,,fee schedule,,,,,,,,,3.95,,,fee schedule,,,,,,,,,3.95,,,fee schedule,,,,,,,,
CEFTAROLINE 400 MG INJ,2500000907,CDM,636,RC,J0712,HCPCS,456040010,NDC,437,EAPG,,outpatient,facility,400,GR,770.62,770.62,151.7,222.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.39,,,fee schedule,,,151.7,,,fee schedule,,,197.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,151.7,,,fee schedule,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTAROLINE 600 MG INJ,2500000908,CDM,636,RC,J0712,HCPCS,456060010,NDC,,,,inpatient,facility,600,GR,809.16,809.16,64.73,809.16,,,,,,,,,,,,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728.24,,,percent of total billed charges,,,,,,,,,809.16,,,percent of total billed charges,,,447.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,738.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,809.16,,,percent of total billed charges,,,421.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.73,,,percent of total billed charges,,,809.16,,,percent of total billed charges,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,568.19,,,percent of total billed charges,,
CEFTAROLINE 600 MG INJ,2500000908,CDM,636,RC,J0712,HCPCS,456060010,NDC,,,,outpatient,facility,600,GR,809.16,809.16,2.55,809.16,,472.55,,,percent of total billed charges,,,,,,,,,809.16,,,percent of total billed charges,,,4.76,,,fee schedule,,,4.59,,,fee schedule,,,,,,,,,4.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,728.24,,,percent of total billed charges,,,,,,,,,809.16,,,percent of total billed charges,,,547.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,621.43,,,percent of total billed charges,,,,,,,,,,,,,,,3.84,,,fee schedule,,,3.84,,,fee schedule,,,,,,,,,618.77,,,per diem,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,421.9,,,percent of total billed charges,,,809.16,,,percent of total billed charges,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,614.96,,,percent of total billed charges,,,306.51,,,percent of total billed charges,,,419.06,,,percent of total billed charges,,,,,,,,,,,,,,,161.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.25,,,fee schedule,,,3.68,,,fee schedule,,,,,,,,,,,,,,,64.73,,,percent of total billed charges,,,809.16,,,percent of total billed charges,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,809.16,,,percent of total billed charges,,,809.16,,,percent of total billed charges,,,,,,,,,809.16,,,fee schedule,,,3.93,,,fee schedule,,,,,,,,,,,,,,,3.45,,,fee schedule,,,4.6,,,fee schedule,,,2.55,,,fee schedule,,,4.18,,,fee schedule,,,809.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,809.16,,,percent of total billed charges,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,568.19,,,percent of total billed charges,,
CEFTAROLINE 600 MG INJ,2500000908,CDM,636,RC,J0712,HCPCS,456060010,NDC,1824,APC,,outpatient,facility,600,GR,809.16,809.16,3.79,296.15,,,,,,,,4.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,fee schedule,,,,,,,,,296.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,3.95,,,fee schedule,,,4.15,,,fee schedule,,,,,,,,,3.95,,,fee schedule,,,3.95,,,fee schedule,,,4.15,,,fee schedule,,,,,,,,,,,,,,,5.73,,,fee schedule,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,3.79,,,fee schedule,,,4.23,,,fee schedule,,,4.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,3.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,3.95,,,fee schedule,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,3.95,,,fee schedule,,,4.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.94,,,fee schedule,,,3.95,,,fee schedule,,,4.11,,,fee schedule,,,3.95,,,fee schedule,,,,,,,,,3.95,,,fee schedule,,,,,,,,,3.95,,,fee schedule,,,,,,,,
CEFTAROLINE 600 MG INJ,2500000908,CDM,636,RC,J0712,HCPCS,456060010,NDC,437,EAPG,,outpatient,facility,600,GR,809.16,809.16,151.7,222.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.39,,,fee schedule,,,151.7,,,fee schedule,,,197.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,151.7,,,fee schedule,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTAZIDIME INJ 1GM,2500000912,CDM,636,RC,J0713,HCPCS,4456723525,NDC,,,,inpatient,facility,1,UN,17.82,17.82,1.43,17.82,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.04,,,percent of total billed charges,,,,,,,,,17.82,,,percent of total billed charges,,,9.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,9.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,
CEFTAZIDIME INJ 1GM,2500000912,CDM,636,RC,J0713,HCPCS,4456723525,NDC,,,,outpatient,facility,1,UN,17.82,17.82,1.43,618.77,,10.41,,,percent of total billed charges,,,3.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,17.82,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,16.04,,,percent of total billed charges,,,,,,,,,17.82,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.29,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.54,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,9.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,17.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.43,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,,,,,,,17.82,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.68,,,fee schedule,,,17.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,17.82,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,12.51,,,percent of total billed charges,,
CEFTAZIDIME INJ 1GM,2500000912,CDM,636,RC,J0713,HCPCS,4456723525,NDC,496,EAPG,,outpatient,facility,1,UN,17.82,17.82,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTAZIDIME INJ 2GM,2500000914,CDM,636,RC,J0713,HCPCS,409508411,NDC,,,,inpatient,facility,2,UN,31.52,31.52,2.52,31.52,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.37,,,percent of total billed charges,,,,,,,,,31.52,,,percent of total billed charges,,,17.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,31.52,,,percent of total billed charges,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.13,,,percent of total billed charges,,
CEFTAZIDIME INJ 2GM,2500000914,CDM,636,RC,J0713,HCPCS,409508411,NDC,,,,outpatient,facility,2,UN,31.52,31.52,1.68,618.77,,18.41,,,percent of total billed charges,,,6.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,31.52,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,28.37,,,percent of total billed charges,,,,,,,,,31.52,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,31.52,,,percent of total billed charges,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.96,,,percent of total billed charges,,,11.94,,,percent of total billed charges,,,16.32,,,percent of total billed charges,,,,,,,,,,,,,,,6.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,31.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.52,,,percent of total billed charges,,,31.52,,,percent of total billed charges,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,31.52,,,percent of total billed charges,,,,,,,,,31.52,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.68,,,fee schedule,,,31.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,31.52,,,percent of total billed charges,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,22.13,,,percent of total billed charges,,
CEFTAZIDIME INJ 2GM,2500000914,CDM,636,RC,J0713,HCPCS,409508411,NDC,496,EAPG,,outpatient,facility,2,UN,31.52,31.52,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROCHLORPERAZINE INJ 10 MG,2500001020,CDM,636,RC,J0780,HCPCS,1478970002,NDC,,,,inpatient,facility,2,ML,59.4,59.4,4.75,59.4,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,32.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,30.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.71,,,percent of total billed charges,,
PROCHLORPERAZINE INJ 10 MG,2500001020,CDM,636,RC,J0780,HCPCS,1478970002,NDC,,,,outpatient,facility,2,ML,59.4,59.4,3.78,618.77,,34.69,,,percent of total billed charges,,,11.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,59.4,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,21.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,53.46,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,40.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.97,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.14,,,percent of total billed charges,,,22.5,,,percent of total billed charges,,,30.76,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,59.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,59.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.75,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,59.4,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.78,,,fee schedule,,,59.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,41.71,,,percent of total billed charges,,
PROCHLORPERAZINE INJ 10 MG,2500001020,CDM,636,RC,J0780,HCPCS,1478970002,NDC,496,EAPG,,outpatient,facility,2,ML,59.4,59.4,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROCHLORPERAZINE 5 MG,2500001026,CDM,636,RC,Q0164,HCPCS,5974611306,NDC,,,,inpatient,facility,5,UN,1.94,1.94,0.16,1.94,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,
PROCHLORPERAZINE 5 MG,2500001026,CDM,636,RC,Q0164,HCPCS,5974611306,NDC,,,,outpatient,facility,5,UN,1.94,1.94,0.16,618.77,,1.13,,,percent of total billed charges,,,0.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.94,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.75,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,1.94,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.43,,,fee schedule,,,1.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.36,,,percent of total billed charges,,
PROCHLORPERAZINE 5 MG,2500001026,CDM,636,RC,Q0164,HCPCS,5974611306,NDC,999,EAPG,,outpatient,facility,5,UN,1.94,1.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COSYNTROPIN INJ PER 0.25 MG,2500001050,CDM,636,RC,J0834,HCPCS,548590000,NDC,,,,inpatient,facility,1,UN,351.71,351.71,28.14,351.71,,,,,,,,,,,,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.54,,,percent of total billed charges,,,,,,,,,351.71,,,percent of total billed charges,,,194.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,351.71,,,percent of total billed charges,,,183.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.14,,,percent of total billed charges,,,351.71,,,percent of total billed charges,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.97,,,percent of total billed charges,,
COSYNTROPIN INJ PER 0.25 MG,2500001050,CDM,636,RC,J0834,HCPCS,548590000,NDC,,,,outpatient,facility,1,UN,351.71,351.71,22.55,618.77,,205.4,,,percent of total billed charges,,,68.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,351.71,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,128.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,316.54,,,percent of total billed charges,,,,,,,,,351.71,,,percent of total billed charges,,,238.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,183.38,,,percent of total billed charges,,,351.71,,,percent of total billed charges,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.3,,,percent of total billed charges,,,133.23,,,percent of total billed charges,,,182.15,,,percent of total billed charges,,,,,,,,,,,,,,,70.34,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,351.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,351.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.14,,,percent of total billed charges,,,351.71,,,percent of total billed charges,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,351.71,,,percent of total billed charges,,,351.71,,,percent of total billed charges,,,,,,,,,351.71,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,22.55,,,fee schedule,,,351.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,351.71,,,percent of total billed charges,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,246.97,,,percent of total billed charges,,
COSYNTROPIN INJ PER 0.25 MG,2500001050,CDM,636,RC,J0834,HCPCS,548590000,NDC,435,EAPG,,outpatient,facility,1,UN,351.71,351.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPREDNISOL ACE INJ 40 MG,2500001130,CDM,636,RC,J1010,HCPCS,9307303,NDC,,,,inpatient,facility,1,UN,37.52,37.52,3,37.52,,,,,,,,,,,,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.77,,,percent of total billed charges,,,,,,,,,37.52,,,percent of total billed charges,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,37.52,,,percent of total billed charges,,,19.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.35,,,percent of total billed charges,,
METHYLPREDNISOL ACE INJ 40 MG,2500001130,CDM,636,RC,J1010,HCPCS,9307303,NDC,,,,outpatient,facility,1,UN,37.52,37.52,0.14,618.77,,21.91,,,percent of total billed charges,,,,,,,,,37.52,,,percent of total billed charges,,,0.17,,,fee schedule,,,0.16,,,fee schedule,,,,,,,,,0.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,33.77,,,percent of total billed charges,,,,,,,,,37.52,,,percent of total billed charges,,,25.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.82,,,percent of total billed charges,,,,,,,,,,,,,,,20.26,,,percent of total billed charges,,,20.26,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.56,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.52,,,percent of total billed charges,,,14.21,,,percent of total billed charges,,,19.43,,,percent of total billed charges,,,,,,,,,,,,,,,7.5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,13.88,,,percent of total billed charges,,,13.88,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,37.52,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,,,,,,,37.52,,,fee schedule,,,34.9,,,percent of total billed charges,,,,,,,,,,,,,,,34.9,,,percent of total billed charges,,,34.9,,,percent of total billed charges,,,34.9,,,percent of total billed charges,,,0.14,,,fee schedule,,,37.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,37.52,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,26.35,,,percent of total billed charges,,
METHYLPREDNISOL ACE INJ 40 MG,2500001130,CDM,636,RC,J1010,HCPCS,9307303,NDC,790,APC,,outpatient,facility,1,UN,37.52,37.52,0.12,13.73,,,,,,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,13.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.13,,,fee schedule,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,0.13,,,fee schedule,,,,,,,,,,,,,,,0.17,,,fee schedule,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.13,,,fee schedule,,,0.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,0.12,,,fee schedule,,,,,,,,,0.12,,,fee schedule,,,,,,,,
METHYLPREDNISOL ACE INJ 40 MG,2500001130,CDM,636,RC,J1010,HCPCS,9307303,NDC,496,EAPG,,outpatient,facility,1,UN,37.52,37.52,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPREDNISOL ACE INJ 80 MG,2500001140,CDM,636,RC,J1010,HCPCS,7012115745,NDC,,,,inpatient,facility,1,UN,64.61,64.61,5.17,64.61,,,,,,,,,,,,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.15,,,percent of total billed charges,,,,,,,,,64.61,,,percent of total billed charges,,,35.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,64.61,,,percent of total billed charges,,,33.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.37,,,percent of total billed charges,,
METHYLPREDNISOL ACE INJ 80 MG,2500001140,CDM,636,RC,J1010,HCPCS,7012115745,NDC,,,,outpatient,facility,1,UN,64.61,64.61,0.14,618.77,,37.73,,,percent of total billed charges,,,,,,,,,64.61,,,percent of total billed charges,,,0.17,,,fee schedule,,,0.16,,,fee schedule,,,,,,,,,0.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,58.15,,,percent of total billed charges,,,,,,,,,64.61,,,percent of total billed charges,,,43.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.62,,,percent of total billed charges,,,,,,,,,,,,,,,34.89,,,percent of total billed charges,,,34.89,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.69,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.1,,,percent of total billed charges,,,24.47,,,percent of total billed charges,,,33.46,,,percent of total billed charges,,,,,,,,,,,,,,,12.92,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,23.91,,,percent of total billed charges,,,23.91,,,percent of total billed charges,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,64.61,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,,,,,,,64.61,,,fee schedule,,,60.1,,,percent of total billed charges,,,,,,,,,,,,,,,60.1,,,percent of total billed charges,,,60.1,,,percent of total billed charges,,,60.1,,,percent of total billed charges,,,0.14,,,fee schedule,,,64.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,64.61,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,45.37,,,percent of total billed charges,,
METHYLPREDNISOL ACE INJ 80 MG,2500001140,CDM,636,RC,J1010,HCPCS,7012115745,NDC,790,APC,,outpatient,facility,1,UN,64.61,64.61,0.12,23.65,,,,,,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,23.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.13,,,fee schedule,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,0.13,,,fee schedule,,,,,,,,,,,,,,,0.17,,,fee schedule,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.13,,,fee schedule,,,0.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,0.12,,,fee schedule,,,,,,,,,0.12,,,fee schedule,,,,,,,,
METHYLPREDNISOL ACE INJ 80 MG,2500001140,CDM,636,RC,J1010,HCPCS,7012115745,NDC,496,EAPG,,outpatient,facility,1,UN,64.61,64.61,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXAMETHASONE  SOD INJ 4MG,2500001221,CDM,636,RC,J1100,HCPCS,641614525,NDC,,,,inpatient,facility,1,ML,3.2,3.2,0.26,3.2,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.88,,,percent of total billed charges,,,,,,,,,3.2,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,
DEXAMETHASONE  SOD INJ 4MG,2500001221,CDM,636,RC,J1100,HCPCS,641614525,NDC,,,,outpatient,facility,1,ML,3.2,3.2,0.12,618.77,,1.87,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.88,,,percent of total billed charges,,,,,,,,,3.2,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,3.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,3.2,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.12,,,fee schedule,,,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.25,,,percent of total billed charges,,
DEXAMETHASONE  SOD INJ 4MG,2500001221,CDM,636,RC,J1100,HCPCS,641614525,NDC,496,EAPG,,outpatient,facility,1,ML,3.2,3.2,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXAMETHASONE  SOD INJ 10 MG,2500001225,CDM,636,RC,J1100,HCPCS,6332350601,NDC,,,,inpatient,facility,1,ML,12.91,12.91,1.03,12.91,,,,,,,,,,,,,,12.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.62,,,percent of total billed charges,,,,,,,,,12.91,,,percent of total billed charges,,,7.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.91,,,percent of total billed charges,,,,,,,,,,,,,,,12.91,,,percent of total billed charges,,,6.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,12.91,,,percent of total billed charges,,,12.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,
DEXAMETHASONE  SOD INJ 10 MG,2500001225,CDM,636,RC,J1100,HCPCS,6332350601,NDC,,,,outpatient,facility,1,ML,12.91,12.91,0.12,618.77,,7.54,,,percent of total billed charges,,,2.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,12.91,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,12.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.62,,,percent of total billed charges,,,,,,,,,12.91,,,percent of total billed charges,,,8.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,12.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.73,,,percent of total billed charges,,,12.91,,,percent of total billed charges,,,12.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.81,,,percent of total billed charges,,,4.89,,,percent of total billed charges,,,6.69,,,percent of total billed charges,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,12.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.03,,,percent of total billed charges,,,12.91,,,percent of total billed charges,,,12.91,,,percent of total billed charges,,,,,,,,,,,,,,,12.91,,,percent of total billed charges,,,12.91,,,percent of total billed charges,,,,,,,,,12.91,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.12,,,fee schedule,,,12.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,12.91,,,percent of total billed charges,,,12.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.07,,,percent of total billed charges,,
DEXAMETHASONE  SOD INJ 10 MG,2500001225,CDM,636,RC,J1100,HCPCS,6332350601,NDC,496,EAPG,,outpatient,facility,1,ML,12.91,12.91,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAZOLAMIDE SOD INJ  500 MG,2500001240,CDM,636,RC,J1120,HCPCS,143950301,NDC,,,,inpatient,facility,500,UN,145.07,145.07,11.61,145.07,,,,,,,,,,,,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.56,,,percent of total billed charges,,,,,,,,,145.07,,,percent of total billed charges,,,80.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,145.07,,,percent of total billed charges,,,75.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,145.07,,,percent of total billed charges,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.87,,,percent of total billed charges,,
ACETAZOLAMIDE SOD INJ  500 MG,2500001240,CDM,636,RC,J1120,HCPCS,143950301,NDC,,,,outpatient,facility,500,UN,145.07,145.07,11.61,618.77,,84.72,,,percent of total billed charges,,,28.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,145.07,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,53.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,130.56,,,percent of total billed charges,,,,,,,,,145.07,,,percent of total billed charges,,,98.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,75.64,,,percent of total billed charges,,,145.07,,,percent of total billed charges,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.25,,,percent of total billed charges,,,54.95,,,percent of total billed charges,,,75.13,,,percent of total billed charges,,,,,,,,,,,,,,,29.01,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,145.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,145.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.61,,,percent of total billed charges,,,145.07,,,percent of total billed charges,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,145.07,,,percent of total billed charges,,,145.07,,,percent of total billed charges,,,,,,,,,145.07,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,24.94,,,fee schedule,,,145.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,145.07,,,percent of total billed charges,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,101.87,,,percent of total billed charges,,
ACETAZOLAMIDE SOD INJ  500 MG,2500001240,CDM,636,RC,J1120,HCPCS,143950301,NDC,999,EAPG,,outpatient,facility,500,UN,145.07,145.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIGOXIN 0.5 MG/2 ML AMP,2500001250,CDM,636,RC,J1160,HCPCS,781305995,NDC,,,,inpatient,facility,2,UN,24.68,24.68,1.97,24.68,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.21,,,percent of total billed charges,,,,,,,,,24.68,,,percent of total billed charges,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.33,,,percent of total billed charges,,
DIGOXIN 0.5 MG/2 ML AMP,2500001250,CDM,636,RC,J1160,HCPCS,781305995,NDC,,,,outpatient,facility,2,UN,24.68,24.68,1.97,618.77,,14.41,,,percent of total billed charges,,,4.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,24.68,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22.21,,,percent of total billed charges,,,,,,,,,24.68,,,percent of total billed charges,,,16.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.95,,,percent of total billed charges,,,,,,,,,,,,,,,9.41,,,fee schedule,,,9.41,,,fee schedule,,,,,,,,,618.77,,,per diem,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.76,,,percent of total billed charges,,,9.35,,,percent of total billed charges,,,12.78,,,percent of total billed charges,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,24.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.97,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,24.68,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,7.45,,,fee schedule,,,24.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,24.68,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.33,,,percent of total billed charges,,
DIGOXIN 0.5 MG/2 ML AMP,2500001250,CDM,636,RC,J1160,HCPCS,781305995,NDC,496,EAPG,,outpatient,facility,2,UN,24.68,24.68,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYTOIN  SOD INJ 100 MG,2500001262,CDM,636,RC,J1165,HCPCS,641049325,NDC,,,,inpatient,facility,2,ML,4.59,4.59,0.37,4.59,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,,,,,,,4.59,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,
PHENYTOIN  SOD INJ 100 MG,2500001262,CDM,636,RC,J1165,HCPCS,641049325,NDC,,,,outpatient,facility,2,ML,4.59,4.59,0.37,618.77,,2.68,,,percent of total billed charges,,,0.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.59,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.13,,,percent of total billed charges,,,,,,,,,4.59,,,percent of total billed charges,,,3.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,4.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,,,,,,,4.59,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.52,,,fee schedule,,,4.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.59,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.22,,,percent of total billed charges,,
PHENYTOIN  SOD INJ 100 MG,2500001262,CDM,636,RC,J1165,HCPCS,641049325,NDC,999,EAPG,,outpatient,facility,2,ML,4.59,4.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYTOIN  SOD INJ 250 MG,2500001264,CDM,636,RC,J1165,HCPCS,641255545,NDC,,,,inpatient,facility,5,UN,6.56,6.56,0.52,6.56,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.9,,,percent of total billed charges,,,,,,,,,6.56,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,3.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.61,,,percent of total billed charges,,
PHENYTOIN  SOD INJ 250 MG,2500001264,CDM,636,RC,J1165,HCPCS,641255545,NDC,,,,outpatient,facility,5,UN,6.56,6.56,0.52,618.77,,3.83,,,percent of total billed charges,,,1.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.56,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.9,,,percent of total billed charges,,,,,,,,,6.56,,,percent of total billed charges,,,4.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.42,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.99,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,6.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.52,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,6.56,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.52,,,fee schedule,,,6.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.61,,,percent of total billed charges,,
PHENYTOIN  SOD INJ 250 MG,2500001264,CDM,636,RC,J1165,HCPCS,641255545,NDC,999,EAPG,,outpatient,facility,5,UN,6.56,6.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROMORPHONE INJ UP TO 20 MG,2500001274,CDM,636,RC,J1171,HCPCS,1747854050,NDC,,,,inpatient,facility,100,UN,841.5,841.5,67.32,841.5,,,,,,,,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,757.35,,,percent of total billed charges,,,,,,,,,841.5,,,percent of total billed charges,,,465.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,841.5,,,percent of total billed charges,,,438.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,590.9,,,percent of total billed charges,,
HYDROMORPHONE INJ UP TO 20 MG,2500001274,CDM,636,RC,J1171,HCPCS,1747854050,NDC,,,,outpatient,facility,100,UN,841.5,841.5,67.32,841.5,,491.44,,,percent of total billed charges,,,,,,,,,841.5,,,percent of total billed charges,,,740.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,740.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,740.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,757.35,,,percent of total billed charges,,,,,,,,,841.5,,,percent of total billed charges,,,569.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,646.27,,,percent of total billed charges,,,,,,,,,,,,,,,454.41,,,percent of total billed charges,,,454.41,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.76,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,639.54,,,percent of total billed charges,,,318.76,,,percent of total billed charges,,,435.81,,,percent of total billed charges,,,,,,,,,,,,,,,168.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,311.36,,,percent of total billed charges,,,311.36,,,percent of total billed charges,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,841.5,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,,,,,,,841.5,,,fee schedule,,,782.76,,,percent of total billed charges,,,,,,,,,,,,,,,782.76,,,percent of total billed charges,,,782.76,,,percent of total billed charges,,,782.76,,,percent of total billed charges,,,631.13,,,percent of total billed charges,,,841.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,841.5,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,590.9,,,percent of total billed charges,,
HYDROMORPHONE INJ UP TO 20 MG,2500001274,CDM,636,RC,J1171,HCPCS,1747854050,NDC,791,APC,,outpatient,facility,100,UN,841.5,841.5,0.09,307.99,,,,,,,,0.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,307.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.13,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.1,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,
HYDROMORPHONE INJ UP TO 20 MG,2500001274,CDM,636,RC,J1171,HCPCS,1747854050,NDC,999,EAPG,,outpatient,facility,100,UN,841.5,841.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROMORPHONE 2 MG/ML INJ,2500001277,CDM,636,RC,J1171,HCPCS,641615125,NDC,,,,inpatient,facility,1,ML,9.9,9.9,0.79,9.9,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,5.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.95,,,percent of total billed charges,,
HYDROMORPHONE 2 MG/ML INJ,2500001277,CDM,636,RC,J1171,HCPCS,641615125,NDC,,,,outpatient,facility,1,ML,9.9,9.9,0.79,618.77,,5.78,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,8.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,8.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,8.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.91,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,5.35,,,percent of total billed charges,,,5.35,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.16,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.52,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.66,,,percent of total billed charges,,,3.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,9.9,,,fee schedule,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,9.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.95,,,percent of total billed charges,,
HYDROMORPHONE 2 MG/ML INJ,2500001277,CDM,636,RC,J1171,HCPCS,641615125,NDC,791,APC,,outpatient,facility,1,ML,9.9,9.9,0.09,3.62,,,,,,,,0.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,3.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.13,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.1,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,
HYDROMORPHONE 2 MG/ML INJ,2500001277,CDM,636,RC,J1171,HCPCS,641615125,NDC,999,EAPG,,outpatient,facility,1,ML,9.9,9.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROMORPHONE 1 MG INJ,2500001279,CDM,636,RC,J1171,HCPCS,6155316267,NDC,,,,inpatient,facility,5,UN,8.58,8.58,0.69,8.58,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,,,,8.58,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,4.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,
HYDROMORPHONE 1 MG INJ,2500001279,CDM,636,RC,J1171,HCPCS,6155316267,NDC,,,,outpatient,facility,5,UN,8.58,8.58,0.69,618.77,,5.01,,,percent of total billed charges,,,,,,,,,8.58,,,percent of total billed charges,,,7.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.72,,,percent of total billed charges,,,,,,,,,8.58,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.59,,,percent of total billed charges,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,4.63,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.47,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.52,,,percent of total billed charges,,,3.25,,,percent of total billed charges,,,4.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,8.58,,,fee schedule,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,6.44,,,percent of total billed charges,,,8.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.58,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.02,,,percent of total billed charges,,
HYDROMORPHONE 1 MG INJ,2500001279,CDM,636,RC,J1171,HCPCS,6155316267,NDC,791,APC,,outpatient,facility,5,UN,8.58,8.58,0.09,3.14,,,,,,,,0.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,3.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.13,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.1,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,
HYDROMORPHONE 1 MG INJ,2500001279,CDM,636,RC,J1171,HCPCS,6155316267,NDC,999,EAPG,,outpatient,facility,5,UN,8.58,8.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIPHENHYDRAMINE INJ 50 MG,2500001300,CDM,636,RC,J1200,HCPCS,,,,,,inpatient,facility,50,UN,9.93,9.93,0.79,9.93,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.94,,,percent of total billed charges,,,,,,,,,9.93,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.97,,,percent of total billed charges,,
DIPHENHYDRAMINE INJ 50 MG,2500001300,CDM,636,RC,J1200,HCPCS,,,,,,outpatient,facility,50,UN,9.93,9.93,0.79,618.77,,5.8,,,percent of total billed charges,,,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.93,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.94,,,percent of total billed charges,,,,,,,,,9.93,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.55,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,5.14,,,percent of total billed charges,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,9.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,9.93,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.95,,,fee schedule,,,9.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.93,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.97,,,percent of total billed charges,,
DIPHENHYDRAMINE INJ 50 MG,2500001300,CDM,636,RC,J1200,HCPCS,496,EAPG,,,,outpatient,facility,50,UN,9.93,9.93,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOBUTAMINE 500 MG IV,2500001365,CDM,636,RC,J1250,HCPCS,409234732,NDC,,,,inpatient,facility,250,UN,46.13,46.13,3.69,46.13,,,,,,,,,,,,,,46.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.52,,,percent of total billed charges,,,,,,,,,46.13,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.13,,,percent of total billed charges,,,,,,,,,,,,,,,46.13,,,percent of total billed charges,,,24.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.69,,,percent of total billed charges,,,46.13,,,percent of total billed charges,,,46.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.39,,,percent of total billed charges,,
DOBUTAMINE 500 MG IV,2500001365,CDM,636,RC,J1250,HCPCS,409234732,NDC,,,,outpatient,facility,250,UN,46.13,46.13,3.69,618.77,,26.94,,,percent of total billed charges,,,9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,46.13,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,46.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,41.52,,,percent of total billed charges,,,,,,,,,46.13,,,percent of total billed charges,,,31.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,46.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.05,,,percent of total billed charges,,,46.13,,,percent of total billed charges,,,46.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.06,,,percent of total billed charges,,,17.47,,,percent of total billed charges,,,23.89,,,percent of total billed charges,,,,,,,,,,,,,,,9.23,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,46.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.69,,,percent of total billed charges,,,46.13,,,percent of total billed charges,,,46.13,,,percent of total billed charges,,,,,,,,,,,,,,,46.13,,,percent of total billed charges,,,46.13,,,percent of total billed charges,,,,,,,,,46.13,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,7.87,,,fee schedule,,,46.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,46.13,,,percent of total billed charges,,,46.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,32.39,,,percent of total billed charges,,
DOBUTAMINE 500 MG IV,2500001365,CDM,636,RC,J1250,HCPCS,409234732,NDC,999,EAPG,,outpatient,facility,250,UN,46.13,46.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ERYTHROMYCIN LACT INJ 500 MG,2500001410,CDM,636,RC,J1364,HCPCS,409647644,NDC,,,,inpatient,facility,500,UN,299.9,299.9,23.99,299.9,,,,,,,,,,,,,,299.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,269.91,,,percent of total billed charges,,,,,,,,,299.9,,,percent of total billed charges,,,166.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,273.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.9,,,percent of total billed charges,,,,,,,,,,,,,,,299.9,,,percent of total billed charges,,,156.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,299.9,,,percent of total billed charges,,,299.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,299.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210.59,,,percent of total billed charges,,
ERYTHROMYCIN LACT INJ 500 MG,2500001410,CDM,636,RC,J1364,HCPCS,409647644,NDC,,,,outpatient,facility,500,UN,299.9,299.9,23.99,618.77,,175.14,,,percent of total billed charges,,,58.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,299.9,,,percent of total billed charges,,,82.49,,,fee schedule,,,79.49,,,fee schedule,,,,,,,,,79.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,299.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,109.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,269.91,,,percent of total billed charges,,,,,,,,,299.9,,,percent of total billed charges,,,203.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.32,,,percent of total billed charges,,,,,,,,,,,,,,,80.78,,,fee schedule,,,80.78,,,fee schedule,,,,,,,,,618.77,,,per diem,,,299.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,156.37,,,percent of total billed charges,,,299.9,,,percent of total billed charges,,,299.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.92,,,percent of total billed charges,,,113.6,,,percent of total billed charges,,,155.32,,,percent of total billed charges,,,,,,,,,,,,,,,59.98,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,182.96,,,fee schedule,,,81.57,,,fee schedule,,,299.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,299.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.99,,,percent of total billed charges,,,299.9,,,percent of total billed charges,,,299.9,,,percent of total billed charges,,,,,,,,,,,,,,,299.9,,,percent of total billed charges,,,299.9,,,percent of total billed charges,,,,,,,,,299.9,,,fee schedule,,,87.05,,,fee schedule,,,,,,,,,,,,,,,76.55,,,fee schedule,,,102.06,,,fee schedule,,,56.58,,,fee schedule,,,72.41,,,fee schedule,,,299.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,299.9,,,percent of total billed charges,,,299.9,,,percent of total billed charges,,,65.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,210.59,,,percent of total billed charges,,
ERYTHROMYCIN LACT INJ 500 MG,2500001410,CDM,636,RC,J1364,HCPCS,409647644,NDC,999,EAPG,,outpatient,facility,500,UN,299.9,299.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FIDAXOMICIN 200 MG TAB,2500001465,CDM,637,RC,5201508001,NDC,,,,,,inpatient,facility,200,UN,821.83,821.83,65.75,821.83,,,,,,,,,,,,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.65,,,percent of total billed charges,,,,,,,,,821.83,,,percent of total billed charges,,,454.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,749.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,821.83,,,percent of total billed charges,,,428.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.75,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.09,,,percent of total billed charges,,
FIDAXOMICIN 200 MG TAB,2500001465,CDM,637,RC,5201508001,NDC,,,,,,outpatient,facility,200,UN,821.83,821.83,65.75,821.83,,479.95,,,percent of total billed charges,,,160.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,821.83,,,percent of total billed charges,,,723.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,723.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,723.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,300.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,739.65,,,percent of total billed charges,,,,,,,,,821.83,,,percent of total billed charges,,,556.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.17,,,percent of total billed charges,,,,,,,,,,,,,,,443.79,,,percent of total billed charges,,,443.79,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.5,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,624.59,,,percent of total billed charges,,,311.31,,,percent of total billed charges,,,425.63,,,percent of total billed charges,,,,,,,,,,,,,,,164.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,304.08,,,percent of total billed charges,,,304.08,,,percent of total billed charges,,,821.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,821.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,65.75,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,821.83,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,,,,,,,821.83,,,fee schedule,,,764.47,,,percent of total billed charges,,,,,,,,,,,,,,,764.47,,,percent of total billed charges,,,764.47,,,percent of total billed charges,,,764.47,,,percent of total billed charges,,,616.37,,,percent of total billed charges,,,821.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,821.83,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,577.09,,,percent of total billed charges,,
FIDAXOMICIN 200 MG TAB,2500001465,CDM,637,RC,5201508001,NDC,999,EAPG,,,,outpatient,facility,200,UN,821.83,821.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FILGRASTIM 300 MCG INJ,2500001470,CDM,636,RC,J1442,HCPCS,5551392491,NDC,,,,inpatient,facility,0.5,UN,1101.21,1101.21,88.1,1101.21,,,,,,,,,,,,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,991.09,,,percent of total billed charges,,,,,,,,,1101.21,,,percent of total billed charges,,,609.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,1101.21,,,percent of total billed charges,,,574.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.1,,,percent of total billed charges,,,1101.21,,,percent of total billed charges,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.27,,,percent of total billed charges,,
FILGRASTIM 300 MCG INJ,2500001470,CDM,636,RC,J1442,HCPCS,5551392491,NDC,,,,outpatient,facility,0.5,UN,1101.21,1101.21,0.68,1101.21,,643.11,,,percent of total billed charges,,,,,,,,,1101.21,,,percent of total billed charges,,,1.18,,,fee schedule,,,1.14,,,fee schedule,,,,,,,,,1.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,991.09,,,percent of total billed charges,,,,,,,,,1101.21,,,percent of total billed charges,,,745.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,845.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,fee schedule,,,0.99,,,fee schedule,,,,,,,,,618.77,,,per diem,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,574.17,,,percent of total billed charges,,,1101.21,,,percent of total billed charges,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.92,,,percent of total billed charges,,,417.14,,,percent of total billed charges,,,570.32,,,percent of total billed charges,,,,,,,,,,,,,,,220.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.18,,,fee schedule,,,0.97,,,fee schedule,,,,,,,,,,,,,,,88.1,,,percent of total billed charges,,,1101.21,,,percent of total billed charges,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,1101.21,,,percent of total billed charges,,,1101.21,,,percent of total billed charges,,,,,,,,,1101.21,,,fee schedule,,,1.04,,,fee schedule,,,,,,,,,,,,,,,0.92,,,fee schedule,,,1.22,,,fee schedule,,,0.68,,,fee schedule,,,1.03,,,fee schedule,,,1101.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1101.21,,,percent of total billed charges,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,773.27,,,percent of total billed charges,,
FILGRASTIM 300 MCG INJ,2500001470,CDM,636,RC,J1442,HCPCS,5551392491,NDC,1469,APC,,outpatient,facility,0.5,UN,1101.21,1101.21,0.94,403.04,,,,,,,,1.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,fee schedule,,,,,,,,,403.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.98,,,fee schedule,,,,,,,,,,,,,,,0.98,,,fee schedule,,,1.03,,,fee schedule,,,,,,,,,0.98,,,fee schedule,,,0.98,,,fee schedule,,,1.03,,,fee schedule,,,,,,,,,,,,,,,1.42,,,fee schedule,,,,,,,,,,,,,,,0.98,,,fee schedule,,,,,,,,,,,,,,,0.94,,,fee schedule,,,1.05,,,fee schedule,,,1.03,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,fee schedule,,,0.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.98,,,fee schedule,,,0.98,,,fee schedule,,,,,,,,,,,,,,,0.98,,,fee schedule,,,,,,,,,,,,,,,0.98,,,fee schedule,,,1.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,0.98,,,fee schedule,,,1.02,,,fee schedule,,,0.98,,,fee schedule,,,,,,,,,0.98,,,fee schedule,,,,,,,,,0.98,,,fee schedule,,,,,,,,
FILGRASTIM 300 MCG INJ,2500001470,CDM,636,RC,J1442,HCPCS,5551392491,NDC,438,EAPG,,outpatient,facility,0.5,UN,1101.21,1101.21,323.15,473.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.74,,,fee schedule,,,323.15,,,fee schedule,,,421.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FILGRASTIM 480 MCG INJ,2500001480,CDM,636,RC,J1442,HCPCS,5551320910,NDC,,,,inpatient,facility,0.8,UN,1753.72,1753.72,140.3,1753.72,,,,,,,,,,,,,,1753.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1578.35,,,percent of total billed charges,,,,,,,,,1753.72,,,percent of total billed charges,,,970.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1600.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1753.72,,,percent of total billed charges,,,,,,,,,,,,,,,1753.72,,,percent of total billed charges,,,914.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.3,,,percent of total billed charges,,,1753.72,,,percent of total billed charges,,,1753.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1753.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1231.46,,,percent of total billed charges,,
FILGRASTIM 480 MCG INJ,2500001480,CDM,636,RC,J1442,HCPCS,5551320910,NDC,,,,outpatient,facility,0.8,UN,1753.72,1753.72,0.68,1753.72,,1024.17,,,percent of total billed charges,,,,,,,,,1753.72,,,percent of total billed charges,,,1.18,,,fee schedule,,,1.14,,,fee schedule,,,,,,,,,1.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1753.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1578.35,,,percent of total billed charges,,,,,,,,,1753.72,,,percent of total billed charges,,,1187.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1346.86,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,fee schedule,,,0.99,,,fee schedule,,,,,,,,,618.77,,,per diem,,,1753.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,914.39,,,percent of total billed charges,,,1753.72,,,percent of total billed charges,,,1753.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1332.83,,,percent of total billed charges,,,664.31,,,percent of total billed charges,,,908.25,,,percent of total billed charges,,,,,,,,,,,,,,,350.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.18,,,fee schedule,,,0.97,,,fee schedule,,,,,,,,,,,,,,,140.3,,,percent of total billed charges,,,1753.72,,,percent of total billed charges,,,1753.72,,,percent of total billed charges,,,,,,,,,,,,,,,1753.72,,,percent of total billed charges,,,1753.72,,,percent of total billed charges,,,,,,,,,1753.72,,,fee schedule,,,1.04,,,fee schedule,,,,,,,,,,,,,,,0.92,,,fee schedule,,,1.22,,,fee schedule,,,0.68,,,fee schedule,,,1.03,,,fee schedule,,,1753.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1753.72,,,percent of total billed charges,,,1753.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,876.86,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1231.46,,,percent of total billed charges,,
FILGRASTIM 480 MCG INJ,2500001480,CDM,636,RC,J1442,HCPCS,5551320910,NDC,1469,APC,,outpatient,facility,0.8,UN,1753.72,1753.72,0.94,641.86,,,,,,,,1.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,fee schedule,,,,,,,,,641.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.98,,,fee schedule,,,,,,,,,,,,,,,0.98,,,fee schedule,,,1.03,,,fee schedule,,,,,,,,,0.98,,,fee schedule,,,0.98,,,fee schedule,,,1.03,,,fee schedule,,,,,,,,,,,,,,,1.42,,,fee schedule,,,,,,,,,,,,,,,0.98,,,fee schedule,,,,,,,,,,,,,,,0.94,,,fee schedule,,,1.05,,,fee schedule,,,1.03,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,fee schedule,,,0.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.98,,,fee schedule,,,0.98,,,fee schedule,,,,,,,,,,,,,,,0.98,,,fee schedule,,,,,,,,,,,,,,,0.98,,,fee schedule,,,1.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,0.98,,,fee schedule,,,1.02,,,fee schedule,,,0.98,,,fee schedule,,,,,,,,,0.98,,,fee schedule,,,,,,,,,0.98,,,fee schedule,,,,,,,,
FILGRASTIM 480 MCG INJ,2500001480,CDM,636,RC,J1442,HCPCS,5551320910,NDC,438,EAPG,,outpatient,facility,0.8,UN,1753.72,1753.72,323.15,473.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.74,,,fee schedule,,,323.15,,,fee schedule,,,421.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENTAMICIN IV PREMIX 120 MG,2500001651,CDM,636,RC,J1580,HCPCS,338050748,NDC,,,,inpatient,facility,100,UN,13.73,13.73,1.1,13.73,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.36,,,percent of total billed charges,,,,,,,,,13.73,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.64,,,percent of total billed charges,,
GENTAMICIN IV PREMIX 120 MG,2500001651,CDM,636,RC,J1580,HCPCS,338050748,NDC,,,,outpatient,facility,100,UN,13.73,13.73,1.1,618.77,,8.02,,,percent of total billed charges,,,2.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.73,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.36,,,percent of total billed charges,,,,,,,,,13.73,,,percent of total billed charges,,,9.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.43,,,percent of total billed charges,,,5.2,,,percent of total billed charges,,,7.11,,,percent of total billed charges,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,13.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,13.73,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.15,,,fee schedule,,,13.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.73,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.64,,,percent of total billed charges,,
GENTAMICIN IV PREMIX 120 MG,2500001651,CDM,636,RC,J1580,HCPCS,338050748,NDC,496,EAPG,,outpatient,facility,100,UN,13.73,13.73,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENTAMICIN 80 MG/2 ML INJ,2500001653,CDM,636,RC,J1580,HCPCS,6332301020,NDC,,,,inpatient,facility,100,UN,15.31,15.31,1.22,15.31,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.78,,,percent of total billed charges,,,,,,,,,15.31,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.75,,,percent of total billed charges,,
GENTAMICIN 80 MG/2 ML INJ,2500001653,CDM,636,RC,J1580,HCPCS,6332301020,NDC,,,,outpatient,facility,100,UN,15.31,15.31,1.22,618.77,,8.94,,,percent of total billed charges,,,2.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,15.31,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.78,,,percent of total billed charges,,,,,,,,,15.31,,,percent of total billed charges,,,10.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.64,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,7.93,,,percent of total billed charges,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,15.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.22,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,15.31,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.15,,,fee schedule,,,15.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,15.31,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.75,,,percent of total billed charges,,
GENTAMICIN 80 MG/2 ML INJ,2500001653,CDM,636,RC,J1580,HCPCS,6332301020,NDC,496,EAPG,,outpatient,facility,100,UN,15.31,15.31,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENTAMICIN 80MG/50ML NS PREMIX,2500001657,CDM,636,RC,J1580,HCPCS,338050941,NDC,,,,inpatient,facility,50,UN,13.43,13.43,1.07,13.43,,,,,,,,,,,,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,,,,,,,13.43,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,13.43,,,percent of total billed charges,,,7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.43,,,percent of total billed charges,,
GENTAMICIN 80MG/50ML NS PREMIX,2500001657,CDM,636,RC,J1580,HCPCS,338050941,NDC,,,,outpatient,facility,50,UN,13.43,13.43,1.07,618.77,,7.84,,,percent of total billed charges,,,2.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.43,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.09,,,percent of total billed charges,,,,,,,,,13.43,,,percent of total billed charges,,,9.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.21,,,percent of total billed charges,,,5.09,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,2.69,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,13.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.07,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,13.43,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,,,,,,,13.43,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.15,,,fee schedule,,,13.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.43,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.43,,,percent of total billed charges,,
GENTAMICIN 80MG/50ML NS PREMIX,2500001657,CDM,636,RC,J1580,HCPCS,338050941,NDC,496,EAPG,,outpatient,facility,50,UN,13.43,13.43,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLUCAGON HCL INJ 1 MG,2500001670,CDM,636,RC,J1610,HCPCS,548585000,NDC,,,,inpatient,facility,1,UN,924,924,73.92,924,,,,,,,,,,,,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,831.6,,,percent of total billed charges,,,,,,,,,924,,,percent of total billed charges,,,511.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,843.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,924,,,percent of total billed charges,,,481.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.92,,,percent of total billed charges,,,924,,,percent of total billed charges,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,648.83,,,percent of total billed charges,,
GLUCAGON HCL INJ 1 MG,2500001670,CDM,636,RC,J1610,HCPCS,548585000,NDC,,,,outpatient,facility,1,UN,924,924,73.92,924,,539.62,,,percent of total billed charges,,,,,,,,,924,,,percent of total billed charges,,,223.94,,,fee schedule,,,215.79,,,fee schedule,,,,,,,,,215.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,831.6,,,percent of total billed charges,,,,,,,,,924,,,percent of total billed charges,,,625.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,709.63,,,percent of total billed charges,,,,,,,,,,,,,,,188.37,,,fee schedule,,,188.37,,,fee schedule,,,,,,,,,618.77,,,per diem,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,481.77,,,percent of total billed charges,,,924,,,percent of total billed charges,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,702.24,,,percent of total billed charges,,,350.01,,,percent of total billed charges,,,478.54,,,percent of total billed charges,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,375.92,,,fee schedule,,,167.6,,,fee schedule,,,,,,,,,,,,,,,73.92,,,percent of total billed charges,,,924,,,percent of total billed charges,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,924,,,percent of total billed charges,,,924,,,percent of total billed charges,,,,,,,,,924,,,fee schedule,,,178.85,,,fee schedule,,,,,,,,,,,,,,,157.27,,,fee schedule,,,209.69,,,fee schedule,,,116.25,,,fee schedule,,,196.61,,,fee schedule,,,924,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,924,,,percent of total billed charges,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,648.83,,,percent of total billed charges,,
GLUCAGON HCL INJ 1 MG,2500001670,CDM,636,RC,J1610,HCPCS,548585000,NDC,9042,APC,,outpatient,facility,1,UN,924,924,176.81,338.18,,,,,,,,189.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,184.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.02,,,fee schedule,,,,,,,,,338.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,184.18,,,fee schedule,,,,,,,,,,,,,,,184.18,,,fee schedule,,,193.39,,,fee schedule,,,,,,,,,184.18,,,fee schedule,,,184.18,,,fee schedule,,,193.39,,,fee schedule,,,,,,,,,,,,,,,267.06,,,fee schedule,,,,,,,,,,,,,,,184.18,,,fee schedule,,,,,,,,,,,,,,,176.81,,,fee schedule,,,197.07,,,fee schedule,,,193.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.18,,,fee schedule,,,184.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,191.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,230.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,184.18,,,fee schedule,,,184.18,,,fee schedule,,,,,,,,,,,,,,,184.18,,,fee schedule,,,,,,,,,,,,,,,184.18,,,fee schedule,,,189.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.3,,,fee schedule,,,184.18,,,fee schedule,,,191.55,,,fee schedule,,,184.18,,,fee schedule,,,,,,,,,184.18,,,fee schedule,,,,,,,,,184.18,,,fee schedule,,,,,,,,
GLUCAGON HCL INJ 1 MG,2500001670,CDM,636,RC,J1610,HCPCS,548585000,NDC,437,EAPG,,outpatient,facility,1,UN,924,924,151.7,222.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.39,,,fee schedule,,,151.7,,,fee schedule,,,197.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,151.7,,,fee schedule,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HALOPERIDOL LACT INJ 5 MG,2500001710,CDM,636,RC,J1630,HCPCS,6745742612,NDC,,,,inpatient,facility,1,ML,4.75,4.75,0.38,4.75,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,,,,,,,4.75,,,percent of total billed charges,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.34,,,percent of total billed charges,,
HALOPERIDOL LACT INJ 5 MG,2500001710,CDM,636,RC,J1630,HCPCS,6745742612,NDC,,,,outpatient,facility,1,ML,4.75,4.75,0.38,618.77,,2.77,,,percent of total billed charges,,,0.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.28,,,percent of total billed charges,,,,,,,,,4.75,,,percent of total billed charges,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.61,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,4.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.38,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,4.75,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.2,,,fee schedule,,,4.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.34,,,percent of total billed charges,,
HALOPERIDOL LACT INJ 5 MG,2500001710,CDM,636,RC,J1630,HCPCS,6745742612,NDC,496,EAPG,,outpatient,facility,1,ML,4.75,4.75,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HALOPERIDOL DEC INJ 50 MG,2500001720,CDM,636,RC,J1631,HCPCS,7006903003,NDC,,,,inpatient,facility,1,UN,103.13,103.13,8.25,103.13,,,,,,,,,,,,,,103.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.82,,,percent of total billed charges,,,,,,,,,103.13,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.13,,,percent of total billed charges,,,,,,,,,,,,,,,103.13,,,percent of total billed charges,,,53.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,103.13,,,percent of total billed charges,,,103.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.42,,,percent of total billed charges,,
HALOPERIDOL DEC INJ 50 MG,2500001720,CDM,636,RC,J1631,HCPCS,7006903003,NDC,,,,outpatient,facility,1,UN,103.13,103.13,6.78,618.77,,60.23,,,percent of total billed charges,,,20.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,103.13,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,103.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,37.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,92.82,,,percent of total billed charges,,,,,,,,,103.13,,,percent of total billed charges,,,69.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,103.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.77,,,percent of total billed charges,,,103.13,,,percent of total billed charges,,,103.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.38,,,percent of total billed charges,,,39.07,,,percent of total billed charges,,,53.41,,,percent of total billed charges,,,,,,,,,,,,,,,20.63,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,103.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.25,,,percent of total billed charges,,,103.13,,,percent of total billed charges,,,103.13,,,percent of total billed charges,,,,,,,,,,,,,,,103.13,,,percent of total billed charges,,,103.13,,,percent of total billed charges,,,,,,,,,103.13,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,6.78,,,fee schedule,,,103.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,103.13,,,percent of total billed charges,,,103.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,72.42,,,percent of total billed charges,,
HALOPERIDOL DEC INJ 50 MG,2500001720,CDM,636,RC,J1631,HCPCS,7006903003,NDC,435,EAPG,,outpatient,facility,1,UN,103.13,103.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPARIN LOCK FLUSH 30 UNIT 3 M,2500001727,CDM,636,RC,J1642,HCPCS,6425322223,NDC,,,,inpatient,facility,3,UN,9.87,9.87,0.79,9.87,,,,,,,,,,,,,,9.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.88,,,percent of total billed charges,,,,,,,,,9.87,,,percent of total billed charges,,,5.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.87,,,percent of total billed charges,,,,,,,,,,,,,,,9.87,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,9.87,,,percent of total billed charges,,,9.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,
HEPARIN LOCK FLUSH 30 UNIT 3 M,2500001727,CDM,636,RC,J1642,HCPCS,6425322223,NDC,,,,outpatient,facility,3,UN,9.87,9.87,0.02,618.77,,5.76,,,percent of total billed charges,,,1.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.87,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.88,,,percent of total billed charges,,,,,,,,,9.87,,,percent of total billed charges,,,6.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,9.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,9.87,,,percent of total billed charges,,,9.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.5,,,percent of total billed charges,,,3.74,,,percent of total billed charges,,,5.11,,,percent of total billed charges,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,9.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,9.87,,,percent of total billed charges,,,9.87,,,percent of total billed charges,,,,,,,,,,,,,,,9.87,,,percent of total billed charges,,,9.87,,,percent of total billed charges,,,,,,,,,9.87,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.02,,,fee schedule,,,9.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.87,,,percent of total billed charges,,,9.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.93,,,percent of total billed charges,,
HEPARIN LOCK FLUSH 30 UNIT 3 M,2500001727,CDM,636,RC,J1642,HCPCS,6425322223,NDC,496,EAPG,,outpatient,facility,3,UN,9.87,9.87,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPARIN  SOD INJ 5000 U/ML 1ML,2500001732,CDM,636,RC,J1644,HCPCS,2502140201,NDC,,,,inpatient,facility,1,UN,4.95,4.95,0.4,4.95,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,4.95,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,
HEPARIN  SOD INJ 5000 U/ML 1ML,2500001732,CDM,636,RC,J1644,HCPCS,2502140201,NDC,,,,outpatient,facility,1,UN,4.95,4.95,0.24,618.77,,2.89,,,percent of total billed charges,,,0.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.46,,,percent of total billed charges,,,,,,,,,4.95,,,percent of total billed charges,,,3.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,4.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.4,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,4.95,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.24,,,fee schedule,,,4.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.48,,,percent of total billed charges,,
HEPARIN  SOD INJ 5000 U/ML 1ML,2500001732,CDM,636,RC,J1644,HCPCS,2502140201,NDC,496,EAPG,,outpatient,facility,1,UN,4.95,4.95,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPARIN  SOD INJ 25000 U,2500001739,CDM,636,RC,J1644,HCPCS,264958720,NDC,,,,inpatient,facility,250,UN,50.72,50.72,4.06,50.72,,,,,,,,,,,,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.65,,,percent of total billed charges,,,,,,,,,50.72,,,percent of total billed charges,,,28.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,50.72,,,percent of total billed charges,,,26.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.62,,,percent of total billed charges,,
HEPARIN  SOD INJ 25000 U,2500001739,CDM,636,RC,J1644,HCPCS,264958720,NDC,,,,outpatient,facility,250,UN,50.72,50.72,0.24,618.77,,29.62,,,percent of total billed charges,,,9.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,50.72,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,18.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,45.65,,,percent of total billed charges,,,,,,,,,50.72,,,percent of total billed charges,,,34.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.45,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.55,,,percent of total billed charges,,,19.21,,,percent of total billed charges,,,26.27,,,percent of total billed charges,,,,,,,,,,,,,,,10.14,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,50.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,50.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.06,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,50.72,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,,,,,,,50.72,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.24,,,fee schedule,,,50.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,50.72,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.62,,,percent of total billed charges,,
HEPARIN  SOD INJ 25000 U,2500001739,CDM,636,RC,J1644,HCPCS,264958720,NDC,496,EAPG,,outpatient,facility,250,UN,50.72,50.72,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPARIN  SOD INJ 1000 U 1 ML,2500001740,CDM,636,RC,J1644,HCPCS,409272001,NDC,,,,inpatient,facility,1,UN,6.13,6.13,0.49,6.13,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.52,,,percent of total billed charges,,,,,,,,,6.13,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,
HEPARIN  SOD INJ 1000 U 1 ML,2500001740,CDM,636,RC,J1644,HCPCS,409272001,NDC,,,,outpatient,facility,1,UN,6.13,6.13,0.24,618.77,,3.58,,,percent of total billed charges,,,1.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.13,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.52,,,percent of total billed charges,,,,,,,,,6.13,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.66,,,percent of total billed charges,,,2.32,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,6.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.49,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,6.13,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.24,,,fee schedule,,,6.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.13,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.3,,,percent of total billed charges,,
HEPARIN  SOD INJ 1000 U 1 ML,2500001740,CDM,636,RC,J1644,HCPCS,409272001,NDC,496,EAPG,,outpatient,facility,1,UN,6.13,6.13,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPARIN LK FL 10 U/ML 5 ML SYR,2500001741,CDM,636,RC,J1642,HCPCS,6380750055,NDC,,,,inpatient,facility,5,UN,11.55,11.55,0.92,11.55,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.4,,,percent of total billed charges,,,,,,,,,11.55,,,percent of total billed charges,,,6.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.11,,,percent of total billed charges,,
HEPARIN LK FL 10 U/ML 5 ML SYR,2500001741,CDM,636,RC,J1642,HCPCS,6380750055,NDC,,,,outpatient,facility,5,UN,11.55,11.55,0.02,618.77,,6.75,,,percent of total billed charges,,,2.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.4,,,percent of total billed charges,,,,,,,,,11.55,,,percent of total billed charges,,,7.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,5.98,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,11.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,11.55,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.02,,,fee schedule,,,11.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.11,,,percent of total billed charges,,
HEPARIN LK FL 10 U/ML 5 ML SYR,2500001741,CDM,636,RC,J1642,HCPCS,6380750055,NDC,496,EAPG,,outpatient,facility,5,UN,11.55,11.55,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENOXAPARIN SOD INJ 150 MG,2500001759,CDM,636,RC,J1650,HCPCS,6050507984,NDC,,,,inpatient,facility,1,ML,89.1,89.1,7.13,89.1,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.19,,,percent of total billed charges,,,,,,,,,89.1,,,percent of total billed charges,,,49.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,46.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.57,,,percent of total billed charges,,
ENOXAPARIN SOD INJ 150 MG,2500001759,CDM,636,RC,J1650,HCPCS,6050507984,NDC,,,,outpatient,facility,1,ML,89.1,89.1,0.59,618.77,,52.03,,,percent of total billed charges,,,17.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,89.1,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,32.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,80.19,,,percent of total billed charges,,,,,,,,,89.1,,,percent of total billed charges,,,60.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.46,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.72,,,percent of total billed charges,,,33.75,,,percent of total billed charges,,,46.14,,,percent of total billed charges,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,89.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,89.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.13,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,,,,,,,89.1,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,89.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,89.1,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,62.57,,,percent of total billed charges,,
ENOXAPARIN SOD INJ 150 MG,2500001759,CDM,636,RC,J1650,HCPCS,6050507984,NDC,496,EAPG,,outpatient,facility,1,ML,89.1,89.1,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENOXAPARIN  SOD INJ 30 MG,2500001760,CDM,636,RC,J1650,HCPCS,548560100,NDC,,,,inpatient,facility,0.3,ML,14.85,14.85,1.19,14.85,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,,,,,,,14.85,,,percent of total billed charges,,,8.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,7.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.43,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 30 MG,2500001760,CDM,636,RC,J1650,HCPCS,548560100,NDC,,,,outpatient,facility,0.3,ML,14.85,14.85,0.59,618.77,,8.67,,,percent of total billed charges,,,2.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.37,,,percent of total billed charges,,,,,,,,,14.85,,,percent of total billed charges,,,10.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.74,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.29,,,percent of total billed charges,,,5.63,,,percent of total billed charges,,,7.69,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,14.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.19,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,14.85,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,14.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.85,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.43,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 30 MG,2500001760,CDM,636,RC,J1650,HCPCS,548560100,NDC,496,EAPG,,outpatient,facility,0.3,ML,14.85,14.85,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENOXAPARIN  SOD INJ 40 MG,2500001762,CDM,636,RC,J1650,HCPCS,7128843383,NDC,,,,inpatient,facility,0.4,ML,12.14,12.14,0.97,12.14,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.93,,,percent of total billed charges,,,,,,,,,12.14,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.52,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 40 MG,2500001762,CDM,636,RC,J1650,HCPCS,7128843383,NDC,,,,outpatient,facility,0.4,ML,12.14,12.14,0.59,618.77,,7.09,,,percent of total billed charges,,,2.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,12.14,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.93,,,percent of total billed charges,,,,,,,,,12.14,,,percent of total billed charges,,,8.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.23,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,6.29,,,percent of total billed charges,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,12.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.97,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,12.14,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,12.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,12.14,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.52,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 40 MG,2500001762,CDM,636,RC,J1650,HCPCS,7128843383,NDC,496,EAPG,,outpatient,facility,0.4,ML,12.14,12.14,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENOXAPARIN  SOD INJ 120 MG,2500001763,CDM,636,RC,J1650,HCPCS,7128841181,NDC,,,,inpatient,facility,0.8,ML,59.4,59.4,4.75,59.4,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,32.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,30.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.71,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 120 MG,2500001763,CDM,636,RC,J1650,HCPCS,7128841181,NDC,,,,outpatient,facility,0.8,ML,59.4,59.4,0.59,618.77,,34.69,,,percent of total billed charges,,,11.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,59.4,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,21.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,53.46,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,40.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.97,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.14,,,percent of total billed charges,,,22.5,,,percent of total billed charges,,,30.76,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,59.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,59.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.75,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,59.4,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,59.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,41.71,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 120 MG,2500001763,CDM,636,RC,J1650,HCPCS,7128841181,NDC,496,EAPG,,outpatient,facility,0.8,ML,59.4,59.4,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENOXAPARIN  SOD INJ 100 MG,2500001764,CDM,636,RC,J1650,HCPCS,6050507954,NDC,,,,inpatient,facility,1,ML,59.4,59.4,4.75,59.4,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,32.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,30.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.71,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 100 MG,2500001764,CDM,636,RC,J1650,HCPCS,6050507954,NDC,,,,outpatient,facility,1,ML,59.4,59.4,0.59,618.77,,34.69,,,percent of total billed charges,,,11.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,59.4,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,21.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,53.46,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,40.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.97,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.14,,,percent of total billed charges,,,22.5,,,percent of total billed charges,,,30.76,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,59.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,59.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.75,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,59.4,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,59.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,41.71,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 100 MG,2500001764,CDM,636,RC,J1650,HCPCS,6050507954,NDC,496,EAPG,,outpatient,facility,1,ML,59.4,59.4,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENOXAPARIN  SOD INJ 60 MG,2500001766,CDM,636,RC,J1650,HCPCS,6050507934,NDC,,,,inpatient,facility,0.6,ML,35.64,35.64,2.85,35.64,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.08,,,percent of total billed charges,,,,,,,,,35.64,,,percent of total billed charges,,,19.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,18.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.03,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 60 MG,2500001766,CDM,636,RC,J1650,HCPCS,6050507934,NDC,,,,outpatient,facility,0.6,ML,35.64,35.64,0.59,618.77,,20.81,,,percent of total billed charges,,,6.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,35.64,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,13.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,32.08,,,percent of total billed charges,,,,,,,,,35.64,,,percent of total billed charges,,,24.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.58,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,13.5,,,percent of total billed charges,,,18.46,,,percent of total billed charges,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,35.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.85,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,35.64,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,35.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,25.03,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 60 MG,2500001766,CDM,636,RC,J1650,HCPCS,6050507934,NDC,496,EAPG,,outpatient,facility,0.6,ML,35.64,35.64,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENOXAPARIN  SOD INJ 80 MG,2500001768,CDM,636,RC,J1650,HCPCS,6050507944,NDC,,,,inpatient,facility,0.8,ML,47.52,47.52,3.8,47.52,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.77,,,percent of total billed charges,,,,,,,,,47.52,,,percent of total billed charges,,,26.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,24.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.37,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 80 MG,2500001768,CDM,636,RC,J1650,HCPCS,6050507944,NDC,,,,outpatient,facility,0.8,ML,47.52,47.52,0.59,618.77,,27.75,,,percent of total billed charges,,,9.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,47.52,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,42.77,,,percent of total billed charges,,,,,,,,,47.52,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.78,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.12,,,percent of total billed charges,,,18,,,percent of total billed charges,,,24.61,,,percent of total billed charges,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,47.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,47.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.8,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,,,,,,,47.52,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,47.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,47.52,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,33.37,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 80 MG,2500001768,CDM,636,RC,J1650,HCPCS,6050507944,NDC,496,EAPG,,outpatient,facility,0.8,ML,47.52,47.52,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORT SOD SUCC INJ 100 MG,2500001810,CDM,636,RC,J1720,HCPCS,9001104,NDC,,,,inpatient,facility,2,UN,70.72,70.72,5.66,70.72,,,,,,,,,,,,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.65,,,percent of total billed charges,,,,,,,,,70.72,,,percent of total billed charges,,,39.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,70.72,,,percent of total billed charges,,,36.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.66,,,percent of total billed charges,,,70.72,,,percent of total billed charges,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.66,,,percent of total billed charges,,
HYDROCORT SOD SUCC INJ 100 MG,2500001810,CDM,636,RC,J1720,HCPCS,9001104,NDC,,,,outpatient,facility,2,UN,70.72,70.72,5.66,618.77,,41.3,,,percent of total billed charges,,,13.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,70.72,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,25.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,63.65,,,percent of total billed charges,,,,,,,,,70.72,,,percent of total billed charges,,,47.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.87,,,percent of total billed charges,,,70.72,,,percent of total billed charges,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.75,,,percent of total billed charges,,,26.79,,,percent of total billed charges,,,36.63,,,percent of total billed charges,,,,,,,,,,,,,,,14.14,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,70.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,70.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.66,,,percent of total billed charges,,,70.72,,,percent of total billed charges,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,70.72,,,percent of total billed charges,,,70.72,,,percent of total billed charges,,,,,,,,,70.72,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,20.6,,,fee schedule,,,70.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,70.72,,,percent of total billed charges,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,49.66,,,percent of total billed charges,,
HYDROCORT SOD SUCC INJ 100 MG,2500001810,CDM,636,RC,J1720,HCPCS,9001104,NDC,496,EAPG,,outpatient,facility,2,UN,70.72,70.72,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPRANOLOL HCL INJ UP TO 1 MG,2500001910,CDM,636,RC,J1800,HCPCS,6332360401,NDC,,,,inpatient,facility,1,UN,33.23,33.23,2.66,33.23,,,,,,,,,,,,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.91,,,percent of total billed charges,,,,,,,,,33.23,,,percent of total billed charges,,,18.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,33.23,,,percent of total billed charges,,,17.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.66,,,percent of total billed charges,,,33.23,,,percent of total billed charges,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.33,,,percent of total billed charges,,
PROPRANOLOL HCL INJ UP TO 1 MG,2500001910,CDM,636,RC,J1800,HCPCS,6332360401,NDC,,,,outpatient,facility,1,UN,33.23,33.23,2.66,618.77,,19.41,,,percent of total billed charges,,,6.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,33.23,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,12.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,29.91,,,percent of total billed charges,,,,,,,,,33.23,,,percent of total billed charges,,,22.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.33,,,percent of total billed charges,,,33.23,,,percent of total billed charges,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.25,,,percent of total billed charges,,,12.59,,,percent of total billed charges,,,17.21,,,percent of total billed charges,,,,,,,,,,,,,,,6.65,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,33.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.66,,,percent of total billed charges,,,33.23,,,percent of total billed charges,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,33.23,,,percent of total billed charges,,,33.23,,,percent of total billed charges,,,,,,,,,33.23,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,11.5,,,fee schedule,,,33.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,33.23,,,percent of total billed charges,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,23.33,,,percent of total billed charges,,
PROPRANOLOL HCL INJ UP TO 1 MG,2500001910,CDM,636,RC,J1800,HCPCS,6332360401,NDC,496,EAPG,,outpatient,facility,1,UN,33.23,33.23,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOROLAC INJ 30MG,2500001980,CDM,636,RC,J1885,HCPCS,7226611825,NDC,,,,inpatient,facility,1,ML,5.77,5.77,0.46,5.77,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.19,,,percent of total billed charges,,,,,,,,,5.77,,,percent of total billed charges,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.05,,,percent of total billed charges,,
KETOROLAC INJ 30MG,2500001980,CDM,636,RC,J1885,HCPCS,7226611825,NDC,,,,outpatient,facility,1,ML,5.77,5.77,0.46,618.77,,3.37,,,percent of total billed charges,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.19,,,percent of total billed charges,,,,,,,,,5.77,,,percent of total billed charges,,,3.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.39,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,5.77,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.87,,,fee schedule,,,5.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.05,,,percent of total billed charges,,
KETOROLAC INJ 30MG,2500001980,CDM,636,RC,J1885,HCPCS,7226611825,NDC,764,APC,,outpatient,facility,1,ML,5.77,5.77,1.13,5.77,,,,,,,,1.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOROLAC INJ 30MG,2500001980,CDM,636,RC,J1885,HCPCS,7226611825,NDC,496,EAPG,,outpatient,facility,1,ML,5.77,5.77,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOROLAC INJ 60 MG,2500001982,CDM,636,RC,J1885,HCPCS,7261172525,NDC,,,,inpatient,facility,2,ML,4.92,4.92,0.39,4.92,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.43,,,percent of total billed charges,,,,,,,,,4.92,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.45,,,percent of total billed charges,,
KETOROLAC INJ 60 MG,2500001982,CDM,636,RC,J1885,HCPCS,7261172525,NDC,,,,outpatient,facility,2,ML,4.92,4.92,0.39,618.77,,2.87,,,percent of total billed charges,,,,,,,,,4.92,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.43,,,percent of total billed charges,,,,,,,,,4.92,,,percent of total billed charges,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,,,,,,,4.92,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.87,,,fee schedule,,,4.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.92,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.45,,,percent of total billed charges,,
KETOROLAC INJ 60 MG,2500001982,CDM,636,RC,J1885,HCPCS,7261172525,NDC,764,APC,,outpatient,facility,2,ML,4.92,4.92,0.96,4.92,,,,,,,,0.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOROLAC INJ 60 MG,2500001982,CDM,636,RC,J1885,HCPCS,7261172525,NDC,496,EAPG,,outpatient,facility,2,ML,4.92,4.92,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOROLAC INJ 15 MG,2500001984,CDM,636,RC,J1885,HCPCS,7261171925,NDC,,,,inpatient,facility,1,ML,4.16,4.16,0.33,4.16,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,,,,,,,,4.16,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,
KETOROLAC INJ 15 MG,2500001984,CDM,636,RC,J1885,HCPCS,7261171925,NDC,,,,outpatient,facility,1,ML,4.16,4.16,0.33,618.77,,2.43,,,percent of total billed charges,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.74,,,percent of total billed charges,,,,,,,,,4.16,,,percent of total billed charges,,,2.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,4.16,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.87,,,fee schedule,,,4.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.16,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.92,,,percent of total billed charges,,
KETOROLAC INJ 15 MG,2500001984,CDM,636,RC,J1885,HCPCS,7261171925,NDC,764,APC,,outpatient,facility,1,ML,4.16,4.16,0.81,4.16,,,,,,,,0.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOROLAC INJ 15 MG,2500001984,CDM,636,RC,J1885,HCPCS,7261171925,NDC,496,EAPG,,outpatient,facility,1,ML,4.16,4.16,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FUROSEMIDE INJ 40 MG,2500002020,CDM,636,RC,J1940,HCPCS,3600028325,NDC,,,,inpatient,facility,4,ML,3.92,3.92,0.31,3.92,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,3.92,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,
FUROSEMIDE INJ 40 MG,2500002020,CDM,636,RC,J1940,HCPCS,3600028325,NDC,,,,outpatient,facility,4,ML,3.92,3.92,0.31,618.77,,2.29,,,percent of total billed charges,,,0.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.92,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.53,,,percent of total billed charges,,,,,,,,,3.92,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,3.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.31,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,3.92,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.45,,,fee schedule,,,3.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.92,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.75,,,percent of total billed charges,,
FUROSEMIDE INJ 40 MG,2500002020,CDM,636,RC,J1940,HCPCS,3600028325,NDC,999,EAPG,,outpatient,facility,4,ML,3.92,3.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FUROSEMIDE INJ 100 MG,2500002022,CDM,636,RC,J1940,HCPCS,3600028425,NDC,,,,inpatient,facility,10,ML,5.87,5.87,0.47,5.87,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,5.87,,,percent of total billed charges,,,3.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,3.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,
FUROSEMIDE INJ 100 MG,2500002022,CDM,636,RC,J1940,HCPCS,3600028425,NDC,,,,outpatient,facility,10,ML,5.87,5.87,0.45,618.77,,3.43,,,percent of total billed charges,,,1.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.87,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.28,,,percent of total billed charges,,,,,,,,,5.87,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,5.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.47,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,,,,,,,5.87,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.45,,,fee schedule,,,5.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.87,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.12,,,percent of total billed charges,,
FUROSEMIDE INJ 100 MG,2500002022,CDM,636,RC,J1940,HCPCS,3600028425,NDC,999,EAPG,,outpatient,facility,10,ML,5.87,5.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FUROSEMIDE INJ 20MG,2500002024,CDM,636,RC,J1940,HCPCS,3600028225,NDC,,,,inpatient,facility,2,ML,3.56,3.56,0.28,3.56,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,
FUROSEMIDE INJ 20MG,2500002024,CDM,636,RC,J1940,HCPCS,3600028225,NDC,,,,outpatient,facility,2,ML,3.56,3.56,0.28,618.77,,2.08,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.56,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.2,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,3.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,3.56,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.45,,,fee schedule,,,3.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.5,,,percent of total billed charges,,
FUROSEMIDE INJ 20MG,2500002024,CDM,636,RC,J1940,HCPCS,3600028225,NDC,999,EAPG,,outpatient,facility,2,ML,3.56,3.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOCARNITINE INJ  1 GM,2500002040,CDM,636,RC,J1955,HCPCS,5448214701,NDC,,,,inpatient,facility,5,UN,121.34,121.34,9.71,121.34,,,,,,,,,,,,,,121.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.21,,,percent of total billed charges,,,,,,,,,121.34,,,percent of total billed charges,,,67.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.34,,,percent of total billed charges,,,,,,,,,,,,,,,121.34,,,percent of total billed charges,,,63.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.71,,,percent of total billed charges,,,121.34,,,percent of total billed charges,,,121.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,121.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.2,,,percent of total billed charges,,
LEVOCARNITINE INJ  1 GM,2500002040,CDM,636,RC,J1955,HCPCS,5448214701,NDC,,,,outpatient,facility,5,UN,121.34,121.34,9.71,618.77,,70.86,,,percent of total billed charges,,,23.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,121.34,,,percent of total billed charges,,,36.1,,,fee schedule,,,34.79,,,fee schedule,,,,,,,,,34.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,121.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,44.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,109.21,,,percent of total billed charges,,,,,,,,,121.34,,,percent of total billed charges,,,82.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.19,,,percent of total billed charges,,,,,,,,,,,,,,,35.32,,,fee schedule,,,35.32,,,fee schedule,,,,,,,,,618.77,,,per diem,,,121.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.27,,,percent of total billed charges,,,121.34,,,percent of total billed charges,,,121.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,45.96,,,percent of total billed charges,,,62.84,,,percent of total billed charges,,,,,,,,,,,,,,,24.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,61.88,,,fee schedule,,,27.59,,,fee schedule,,,121.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,121.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.71,,,percent of total billed charges,,,121.34,,,percent of total billed charges,,,121.34,,,percent of total billed charges,,,,,,,,,,,,,,,121.34,,,percent of total billed charges,,,121.34,,,percent of total billed charges,,,,,,,,,27.72,,,fee schedule,,,29.44,,,fee schedule,,,,,,,,,,,,,,,25.89,,,fee schedule,,,34.52,,,fee schedule,,,19.14,,,fee schedule,,,31.69,,,fee schedule,,,121.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,121.34,,,percent of total billed charges,,,121.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.67,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,85.2,,,percent of total billed charges,,
LEVOCARNITINE INJ  1 GM,2500002040,CDM,636,RC,J1955,HCPCS,5448214701,NDC,435,EAPG,,outpatient,facility,5,UN,121.34,121.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 1  30 ML INJ,2500002092,CDM,250,RC,J2003,HCPCS,6332349207,NDC,,,,inpatient,facility,30,UN,14.36,14.36,1.15,14.36,,,,,,,,,,,,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.92,,,percent of total billed charges,,,,,,,,,14.36,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,14.36,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,14.36,,,percent of total billed charges,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.08,,,percent of total billed charges,,
LIDOCAINE HCL 1  30 ML INJ,2500002092,CDM,250,RC,J2003,HCPCS,6332349207,NDC,,,,outpatient,facility,30,UN,14.36,14.36,1.15,618.77,,8.39,,,percent of total billed charges,,,2.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.36,,,percent of total billed charges,,,12.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.92,,,percent of total billed charges,,,,,,,,,14.36,,,percent of total billed charges,,,9.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,14.36,,,percent of total billed charges,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.91,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,7.44,,,percent of total billed charges,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.31,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,14.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.15,,,percent of total billed charges,,,14.36,,,percent of total billed charges,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,14.36,,,percent of total billed charges,,,14.36,,,percent of total billed charges,,,,,,,,,14.36,,,fee schedule,,,13.36,,,percent of total billed charges,,,,,,,,,,,,,,,13.36,,,percent of total billed charges,,,13.36,,,percent of total billed charges,,,13.36,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,14.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.36,,,percent of total billed charges,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.08,,,percent of total billed charges,,
LIDOCAINE HCL 1  30 ML INJ,2500002092,CDM,250,RC,J2003,HCPCS,6332349207,NDC,999,EAPG,,outpatient,facility,30,UN,14.36,14.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 1  5 ML AMP,2500002093,CDM,636,RC,J2003,HCPCS,5515015974,NDC,,,,inpatient,facility,5,UN,8.81,8.81,0.7,8.81,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.93,,,percent of total billed charges,,,,,,,,,8.81,,,percent of total billed charges,,,4.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,
LIDOCAINE HCL 1  5 ML AMP,2500002093,CDM,636,RC,J2003,HCPCS,5515015974,NDC,,,,outpatient,facility,5,UN,8.81,8.81,0.7,618.77,,5.15,,,percent of total billed charges,,,1.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.81,,,percent of total billed charges,,,7.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.93,,,percent of total billed charges,,,,,,,,,8.81,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.77,,,percent of total billed charges,,,,,,,,,,,,,,,4.76,,,percent of total billed charges,,,4.76,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,3.34,,,percent of total billed charges,,,4.56,,,percent of total billed charges,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,8.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.7,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,8.81,,,fee schedule,,,8.2,,,percent of total billed charges,,,,,,,,,,,,,,,8.2,,,percent of total billed charges,,,8.2,,,percent of total billed charges,,,8.2,,,percent of total billed charges,,,6.61,,,percent of total billed charges,,,8.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.19,,,percent of total billed charges,,
LIDOCAINE HCL 1  5 ML AMP,2500002093,CDM,636,RC,J2003,HCPCS,5515015974,NDC,999,EAPG,,outpatient,facility,5,UN,8.81,8.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 1  50 ML INJ,2500002094,CDM,250,RC,J2003,HCPCS,143957710,NDC,,,,inpatient,facility,50,UN,9.21,9.21,0.74,9.21,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.29,,,percent of total billed charges,,,,,,,,,9.21,,,percent of total billed charges,,,5.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,4.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.47,,,percent of total billed charges,,
LIDOCAINE HCL 1  50 ML INJ,2500002094,CDM,250,RC,J2003,HCPCS,143957710,NDC,,,,outpatient,facility,50,UN,9.21,9.21,0.74,618.77,,5.38,,,percent of total billed charges,,,1.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.21,,,percent of total billed charges,,,8.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,8.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,8.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.29,,,percent of total billed charges,,,,,,,,,9.21,,,percent of total billed charges,,,6.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.8,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7,,,percent of total billed charges,,,3.49,,,percent of total billed charges,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.41,,,percent of total billed charges,,,3.41,,,percent of total billed charges,,,9.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.74,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,,,,,,,9.21,,,fee schedule,,,8.57,,,percent of total billed charges,,,,,,,,,,,,,,,8.57,,,percent of total billed charges,,,8.57,,,percent of total billed charges,,,8.57,,,percent of total billed charges,,,6.91,,,percent of total billed charges,,,9.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.47,,,percent of total billed charges,,
LIDOCAINE HCL 1  50 ML INJ,2500002094,CDM,250,RC,J2003,HCPCS,143957710,NDC,999,EAPG,,outpatient,facility,50,UN,9.21,9.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LORAZEPAM INJ 2 MG,2500002110,CDM,636,RC,J2060,HCPCS,641604425,NDC,,,,inpatient,facility,1,ML,4.26,4.26,0.34,4.26,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,4.26,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.99,,,percent of total billed charges,,
LORAZEPAM INJ 2 MG,2500002110,CDM,636,RC,J2060,HCPCS,641604425,NDC,,,,outpatient,facility,1,ML,4.26,4.26,0.34,618.77,,2.49,,,percent of total billed charges,,,0.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.26,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.83,,,percent of total billed charges,,,,,,,,,4.26,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.24,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,4.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.34,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,,,,,,,4.26,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.35,,,fee schedule,,,4.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.99,,,percent of total billed charges,,
LORAZEPAM INJ 2 MG,2500002110,CDM,636,RC,J2060,HCPCS,641604425,NDC,496,EAPG,,outpatient,facility,1,ML,4.26,4.26,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MANNITOL INJ 25   50 ML,2500002120,CDM,636,RC,J2150,HCPCS,409403101,NDC,,,,inpatient,facility,50,UN,9.7,9.7,0.78,9.7,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.73,,,percent of total billed charges,,,,,,,,,9.7,,,percent of total billed charges,,,5.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,5.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,9.7,,,percent of total billed charges,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.81,,,percent of total billed charges,,
MANNITOL INJ 25   50 ML,2500002120,CDM,636,RC,J2150,HCPCS,409403101,NDC,,,,outpatient,facility,50,UN,9.7,9.7,0.78,618.77,,5.66,,,percent of total billed charges,,,1.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.73,,,percent of total billed charges,,,,,,,,,9.7,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,,9.7,,,percent of total billed charges,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.37,,,percent of total billed charges,,,3.67,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,9.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.78,,,percent of total billed charges,,,9.7,,,percent of total billed charges,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,9.7,,,percent of total billed charges,,,,,,,,,9.7,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3,,,fee schedule,,,9.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.7,,,percent of total billed charges,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.81,,,percent of total billed charges,,
MANNITOL INJ 25   50 ML,2500002120,CDM,636,RC,J2150,HCPCS,409403101,NDC,496,EAPG,,outpatient,facility,50,UN,9.7,9.7,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEPERIDINE INJ 50 MG,2500002137,CDM,636,RC,J2175,HCPCS,641605301,NDC,,,,inpatient,facility,1,UN,13.2,13.2,1.06,13.2,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,6.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.27,,,percent of total billed charges,,
MEPERIDINE INJ 50 MG,2500002137,CDM,636,RC,J2175,HCPCS,641605301,NDC,,,,outpatient,facility,1,UN,13.2,13.2,1.06,618.77,,7.71,,,percent of total billed charges,,,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.88,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.88,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,5,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,13.2,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,6.25,,,fee schedule,,,13.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.27,,,percent of total billed charges,,
MEPERIDINE INJ 50 MG,2500002137,CDM,636,RC,J2175,HCPCS,641605301,NDC,496,EAPG,,outpatient,facility,1,UN,13.2,13.2,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLERGONOVIN MAL INJ 0.2 MG,2500002150,CDM,636,RC,J2210,HCPCS,5199114417,NDC,,,,inpatient,facility,1,UN,78.24,78.24,6.26,78.24,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.42,,,percent of total billed charges,,,,,,,,,78.24,,,percent of total billed charges,,,43.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,40.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,78.24,,,percent of total billed charges,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.94,,,percent of total billed charges,,
METHYLERGONOVIN MAL INJ 0.2 MG,2500002150,CDM,636,RC,J2210,HCPCS,5199114417,NDC,,,,outpatient,facility,1,UN,78.24,78.24,6.26,618.77,,45.69,,,percent of total billed charges,,,15.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,78.24,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,28.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,70.42,,,percent of total billed charges,,,,,,,,,78.24,,,percent of total billed charges,,,52.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.79,,,percent of total billed charges,,,78.24,,,percent of total billed charges,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.46,,,percent of total billed charges,,,29.64,,,percent of total billed charges,,,40.52,,,percent of total billed charges,,,,,,,,,,,,,,,15.65,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,78.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,78.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.26,,,percent of total billed charges,,,78.24,,,percent of total billed charges,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,78.24,,,percent of total billed charges,,,,,,,,,78.24,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,21.58,,,fee schedule,,,78.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,78.24,,,percent of total billed charges,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,54.94,,,percent of total billed charges,,
METHYLERGONOVIN MAL INJ 0.2 MG,2500002150,CDM,636,RC,J2210,HCPCS,5199114417,NDC,999,EAPG,,outpatient,facility,1,UN,78.24,78.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF INJ UP TO 10 MG,2500002190,CDM,636,RC,J2270,HCPCS,641612725,NDC,,,,inpatient,facility,1,ML,8.42,8.42,0.67,8.42,,,,,,,,,,,,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.58,,,percent of total billed charges,,,,,,,,,8.42,,,percent of total billed charges,,,4.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,8.42,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,
MORPHINE SULF INJ UP TO 10 MG,2500002190,CDM,636,RC,J2270,HCPCS,641612725,NDC,,,,outpatient,facility,1,ML,8.42,8.42,0.67,618.77,,4.92,,,percent of total billed charges,,,1.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.42,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.58,,,percent of total billed charges,,,,,,,,,8.42,,,percent of total billed charges,,,5.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.39,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.4,,,percent of total billed charges,,,3.19,,,percent of total billed charges,,,4.36,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,8.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.67,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,8.42,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,8.42,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.37,,,fee schedule,,,8.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.42,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.91,,,percent of total billed charges,,
MORPHINE SULF INJ UP TO 10 MG,2500002190,CDM,636,RC,J2270,HCPCS,641612725,NDC,496,EAPG,,outpatient,facility,1,ML,8.42,8.42,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE 100MG/100ML NACL PRMX,2500002193,CDM,636,RC,J2270,HCPCS,7128620406,NDC,,,,inpatient,facility,100,UN,33,33,2.64,33,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,17.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.17,,,percent of total billed charges,,
MORPHINE 100MG/100ML NACL PRMX,2500002193,CDM,636,RC,J2270,HCPCS,7128620406,NDC,,,,outpatient,facility,100,UN,33,33,2.64,618.77,,19.27,,,percent of total billed charges,,,6.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,33,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,12.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,29.7,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,22.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.21,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.08,,,percent of total billed charges,,,12.5,,,percent of total billed charges,,,17.09,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,33,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.37,,,fee schedule,,,33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,23.17,,,percent of total billed charges,,
MORPHINE 100MG/100ML NACL PRMX,2500002193,CDM,636,RC,J2270,HCPCS,7128620406,NDC,496,EAPG,,outpatient,facility,100,UN,33,33,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF INJ 2 MG,2500002198,CDM,636,RC,J2270,HCPCS,409189001,NDC,,,,inpatient,facility,1,ML,7.03,7.03,0.56,7.03,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,,,,,,,7.03,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,3.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,
MORPHINE SULF INJ 2 MG,2500002198,CDM,636,RC,J2270,HCPCS,409189001,NDC,,,,outpatient,facility,1,ML,7.03,7.03,0.56,618.77,,4.11,,,percent of total billed charges,,,1.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.03,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.33,,,percent of total billed charges,,,,,,,,,7.03,,,percent of total billed charges,,,4.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.67,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.34,,,percent of total billed charges,,,2.66,,,percent of total billed charges,,,3.64,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,7.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,7.03,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.37,,,fee schedule,,,7.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.94,,,percent of total billed charges,,
MORPHINE SULF INJ 2 MG,2500002198,CDM,636,RC,J2270,HCPCS,409189001,NDC,496,EAPG,,outpatient,facility,1,ML,7.03,7.03,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NALBUPHINE HCL INJ  20 MG,2500002211,CDM,636,RC,J2300,HCPCS,409146701,NDC,,,,inpatient,facility,1,UN,21.91,21.91,1.75,21.91,,,,,,,,,,,,,,21.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.72,,,percent of total billed charges,,,,,,,,,21.91,,,percent of total billed charges,,,12.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.91,,,percent of total billed charges,,,,,,,,,,,,,,,21.91,,,percent of total billed charges,,,11.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,21.91,,,percent of total billed charges,,,21.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.39,,,percent of total billed charges,,
NALBUPHINE HCL INJ  20 MG,2500002211,CDM,636,RC,J2300,HCPCS,409146701,NDC,,,,outpatient,facility,1,UN,21.91,21.91,1.75,618.77,,12.8,,,percent of total billed charges,,,4.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,21.91,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,21.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,19.72,,,percent of total billed charges,,,,,,,,,21.91,,,percent of total billed charges,,,14.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,21.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.42,,,percent of total billed charges,,,21.91,,,percent of total billed charges,,,21.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,,percent of total billed charges,,,8.3,,,percent of total billed charges,,,11.35,,,percent of total billed charges,,,,,,,,,,,,,,,4.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,21.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.75,,,percent of total billed charges,,,21.91,,,percent of total billed charges,,,21.91,,,percent of total billed charges,,,,,,,,,,,,,,,21.91,,,percent of total billed charges,,,21.91,,,percent of total billed charges,,,,,,,,,21.91,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.36,,,fee schedule,,,21.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,21.91,,,percent of total billed charges,,,21.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,15.39,,,percent of total billed charges,,
NALBUPHINE HCL INJ  20 MG,2500002211,CDM,636,RC,J2300,HCPCS,409146701,NDC,496,EAPG,,outpatient,facility,1,UN,21.91,21.91,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRINE HCL INJ 1 ML,2500002290,CDM,636,RC,J2371,HCPCS,6332375101,NDC,,,,inpatient,facility,1,ML,10.56,10.56,0.84,10.56,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,10.56,,,percent of total billed charges,,,5.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.42,,,percent of total billed charges,,
PHENYLEPHRINE HCL INJ 1 ML,2500002290,CDM,636,RC,J2371,HCPCS,6332375101,NDC,,,,outpatient,facility,1,ML,10.56,10.56,0.84,618.77,,6.17,,,percent of total billed charges,,,2.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.56,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.5,,,percent of total billed charges,,,,,,,,,10.56,,,percent of total billed charges,,,7.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.03,,,percent of total billed charges,,,4,,,percent of total billed charges,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,10.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.84,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,10.56,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,7.92,,,percent of total billed charges,,,10.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.42,,,percent of total billed charges,,
PHENYLEPHRINE HCL INJ 1 ML,2500002290,CDM,636,RC,J2371,HCPCS,6332375101,NDC,999,EAPG,,outpatient,facility,1,ML,10.56,10.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRINE 100 MG/250 ML,2500002291,CDM,636,RC,J2371,HCPCS,7101926506,NDC,,,,inpatient,facility,250,ML,230.97,230.97,18.48,230.97,,,,,,,,,,,,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.87,,,percent of total billed charges,,,,,,,,,230.97,,,percent of total billed charges,,,127.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,230.97,,,percent of total billed charges,,,120.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.19,,,percent of total billed charges,,
PHENYLEPHRINE 100 MG/250 ML,2500002291,CDM,636,RC,J2371,HCPCS,7101926506,NDC,,,,outpatient,facility,250,ML,230.97,230.97,18.48,618.77,,134.89,,,percent of total billed charges,,,45.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,230.97,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,84.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,207.87,,,percent of total billed charges,,,,,,,,,230.97,,,percent of total billed charges,,,156.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,120.43,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.54,,,percent of total billed charges,,,87.49,,,percent of total billed charges,,,119.62,,,percent of total billed charges,,,,,,,,,,,,,,,46.19,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,230.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,230.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.48,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,230.97,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,,,,,,,230.97,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,173.23,,,percent of total billed charges,,,230.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,230.97,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,162.19,,,percent of total billed charges,,
PHENYLEPHRINE 100 MG/250 ML,2500002291,CDM,636,RC,J2371,HCPCS,7101926506,NDC,999,EAPG,,outpatient,facility,250,ML,230.97,230.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRINE 50 MG/250 ML,2500002292,CDM,636,RC,J2371,HCPCS,4202321410,NDC,,,,inpatient,facility,250,ML,146.78,146.78,11.74,146.78,,,,,,,,,,,,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.1,,,percent of total billed charges,,,,,,,,,146.78,,,percent of total billed charges,,,81.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,146.78,,,percent of total billed charges,,,76.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.07,,,percent of total billed charges,,
PHENYLEPHRINE 50 MG/250 ML,2500002292,CDM,636,RC,J2371,HCPCS,4202321410,NDC,,,,outpatient,facility,250,ML,146.78,146.78,11.74,618.77,,85.72,,,percent of total billed charges,,,28.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,146.78,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,53.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,132.1,,,percent of total billed charges,,,,,,,,,146.78,,,percent of total billed charges,,,99.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,76.53,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.55,,,percent of total billed charges,,,55.6,,,percent of total billed charges,,,76.02,,,percent of total billed charges,,,,,,,,,,,,,,,29.36,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,146.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,146.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.74,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,146.78,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,,,,,,,146.78,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,110.09,,,percent of total billed charges,,,146.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,146.78,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,103.07,,,percent of total billed charges,,
PHENYLEPHRINE 50 MG/250 ML,2500002292,CDM,636,RC,J2371,HCPCS,4202321410,NDC,999,EAPG,,outpatient,facility,250,ML,146.78,146.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRINE 50MG/5ML IV,2500002296,CDM,636,RC,J2371,HCPCS,6332375101,NDC,,,,inpatient,facility,10,ML,52.8,52.8,4.22,52.8,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,,,,,,,52.8,,,percent of total billed charges,,,29.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,27.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.08,,,percent of total billed charges,,
PHENYLEPHRINE 50MG/5ML IV,2500002296,CDM,636,RC,J2371,HCPCS,6332375101,NDC,,,,outpatient,facility,10,ML,52.8,52.8,4.22,618.77,,30.84,,,percent of total billed charges,,,10.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,52.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,19.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,47.52,,,percent of total billed charges,,,,,,,,,52.8,,,percent of total billed charges,,,35.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.53,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.13,,,percent of total billed charges,,,20,,,percent of total billed charges,,,27.35,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,52.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,52.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.22,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,52.8,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,39.6,,,percent of total billed charges,,,52.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,37.08,,,percent of total billed charges,,
PHENYLEPHRINE 50MG/5ML IV,2500002296,CDM,636,RC,J2371,HCPCS,6332375101,NDC,999,EAPG,,outpatient,facility,10,ML,52.8,52.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PENICILLIN G K INJ 5000000 U,2500002402,CDM,636,RC,J2540,HCPCS,49052083,NDC,,,,inpatient,facility,5,UN,41.98,41.98,3.36,41.98,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.78,,,percent of total billed charges,,,,,,,,,41.98,,,percent of total billed charges,,,23.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,21.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,41.98,,,percent of total billed charges,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.48,,,percent of total billed charges,,
PENICILLIN G K INJ 5000000 U,2500002402,CDM,636,RC,J2540,HCPCS,49052083,NDC,,,,outpatient,facility,5,UN,41.98,41.98,0.97,618.77,,24.52,,,percent of total billed charges,,,8.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,41.98,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,15.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,37.78,,,percent of total billed charges,,,,,,,,,41.98,,,percent of total billed charges,,,28.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.89,,,percent of total billed charges,,,41.98,,,percent of total billed charges,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.9,,,percent of total billed charges,,,15.9,,,percent of total billed charges,,,21.74,,,percent of total billed charges,,,,,,,,,,,,,,,8.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,41.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,41.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.36,,,percent of total billed charges,,,41.98,,,percent of total billed charges,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,41.98,,,percent of total billed charges,,,,,,,,,41.98,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.97,,,fee schedule,,,41.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,41.98,,,percent of total billed charges,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,29.48,,,percent of total billed charges,,
PENICILLIN G K INJ 5000000 U,2500002402,CDM,636,RC,J2540,HCPCS,49052083,NDC,496,EAPG,,outpatient,facility,5,UN,41.98,41.98,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENOBARBITAL INJ UP TO 120 MG,2500002430,CDM,636,RC,J2560,HCPCS,4249441525,NDC,,,,inpatient,facility,1,UN,86.39,86.39,6.91,86.39,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.75,,,percent of total billed charges,,,,,,,,,86.39,,,percent of total billed charges,,,47.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,45.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.91,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.66,,,percent of total billed charges,,
PHENOBARBITAL INJ UP TO 120 MG,2500002430,CDM,636,RC,J2560,HCPCS,4249441525,NDC,,,,outpatient,facility,1,UN,86.39,86.39,6.91,618.77,,50.45,,,percent of total billed charges,,,16.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,86.39,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,31.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,77.75,,,percent of total billed charges,,,,,,,,,86.39,,,percent of total billed charges,,,58.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,45.04,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.66,,,percent of total billed charges,,,32.72,,,percent of total billed charges,,,44.74,,,percent of total billed charges,,,,,,,,,,,,,,,17.28,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,86.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,86.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.91,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,,,,,,,86.39,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,34.01,,,fee schedule,,,86.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,86.39,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,60.66,,,percent of total billed charges,,
PHENOBARBITAL INJ UP TO 120 MG,2500002430,CDM,636,RC,J2560,HCPCS,4249441525,NDC,435,EAPG,,outpatient,facility,1,UN,86.39,86.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DESMOPRESSIN ACET INJ 4 MCG,2500002453,CDM,636,RC,J2597,HCPCS,4359893109,NDC,,,,inpatient,facility,1,GR,125.4,125.4,10.03,125.4,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.86,,,percent of total billed charges,,,,,,,,,125.4,,,percent of total billed charges,,,69.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,65.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.06,,,percent of total billed charges,,
DESMOPRESSIN ACET INJ 4 MCG,2500002453,CDM,636,RC,J2597,HCPCS,4359893109,NDC,,,,outpatient,facility,1,GR,125.4,125.4,5.19,618.77,,73.23,,,percent of total billed charges,,,,,,,,,125.4,,,percent of total billed charges,,,6.57,,,fee schedule,,,6.33,,,fee schedule,,,,,,,,,6.33,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,112.86,,,percent of total billed charges,,,,,,,,,125.4,,,percent of total billed charges,,,84.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.31,,,percent of total billed charges,,,,,,,,,,,,,,,6.33,,,fee schedule,,,6.33,,,fee schedule,,,,,,,,,618.77,,,per diem,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.38,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.3,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,64.94,,,percent of total billed charges,,,,,,,,,,,,,,,25.08,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,16.8,,,fee schedule,,,7.49,,,fee schedule,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,125.4,,,fee schedule,,,7.99,,,fee schedule,,,,,,,,,,,,,,,7.03,,,fee schedule,,,9.37,,,fee schedule,,,5.19,,,fee schedule,,,5.78,,,fee schedule,,,125.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,125.4,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,88.06,,,percent of total billed charges,,
DESMOPRESSIN ACET INJ 4 MCG,2500002453,CDM,636,RC,J2597,HCPCS,4359893109,NDC,1440,APC,,outpatient,facility,1,GR,125.4,125.4,4.75,45.9,,,,,,,,5.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,4.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5,,,fee schedule,,,,,,,,,45.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,4.95,,,fee schedule,,,,,,,,,,,,,,,4.95,,,fee schedule,,,5.2,,,fee schedule,,,,,,,,,4.95,,,fee schedule,,,4.95,,,fee schedule,,,5.2,,,fee schedule,,,,,,,,,,,,,,,7.18,,,fee schedule,,,,,,,,,,,,,,,4.95,,,fee schedule,,,,,,,,,,,,,,,4.75,,,fee schedule,,,5.3,,,fee schedule,,,5.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,fee schedule,,,4.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,5.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,4.95,,,fee schedule,,,4.95,,,fee schedule,,,,,,,,,,,,,,,4.95,,,fee schedule,,,,,,,,,,,,,,,4.95,,,fee schedule,,,5.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.42,,,fee schedule,,,4.95,,,fee schedule,,,5.15,,,fee schedule,,,4.95,,,fee schedule,,,,,,,,,4.95,,,fee schedule,,,,,,,,,4.95,,,fee schedule,,,,,,,,
DESMOPRESSIN ACET INJ 4 MCG,2500002453,CDM,636,RC,J2597,HCPCS,4359893109,NDC,999,EAPG,,outpatient,facility,1,GR,125.4,125.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUPHENAZINE DECAN INJ 125 MG,2500002502,CDM,636,RC,J2680,HCPCS,6332327205,NDC,,,,inpatient,facility,5,UN,511.4,511.4,40.91,511.4,,,,,,,,,,,,,,511.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,460.26,,,percent of total billed charges,,,,,,,,,511.4,,,percent of total billed charges,,,283.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.4,,,percent of total billed charges,,,,,,,,,,,,,,,511.4,,,percent of total billed charges,,,266.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.91,,,percent of total billed charges,,,511.4,,,percent of total billed charges,,,511.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,511.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.11,,,percent of total billed charges,,
FLUPHENAZINE DECAN INJ 125 MG,2500002502,CDM,636,RC,J2680,HCPCS,6332327205,NDC,,,,outpatient,facility,5,UN,511.4,511.4,9.26,618.77,,298.66,,,percent of total billed charges,,,99.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,511.4,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,511.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,187.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,460.26,,,percent of total billed charges,,,,,,,,,511.4,,,percent of total billed charges,,,346.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,511.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.64,,,percent of total billed charges,,,511.4,,,percent of total billed charges,,,511.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.66,,,percent of total billed charges,,,193.72,,,percent of total billed charges,,,264.85,,,percent of total billed charges,,,,,,,,,,,,,,,102.28,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,511.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,511.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.91,,,percent of total billed charges,,,511.4,,,percent of total billed charges,,,511.4,,,percent of total billed charges,,,,,,,,,,,,,,,511.4,,,percent of total billed charges,,,511.4,,,percent of total billed charges,,,,,,,,,511.4,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,9.26,,,fee schedule,,,511.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,511.4,,,percent of total billed charges,,,511.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,359.11,,,percent of total billed charges,,
FLUPHENAZINE DECAN INJ 125 MG,2500002502,CDM,636,RC,J2680,HCPCS,6332327205,NDC,435,EAPG,,outpatient,facility,5,UN,511.4,511.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXACILLIN  SOD 1 GM,2500002520,CDM,636,RC,J2700,HCPCS,5515012715,NDC,,,,inpatient,facility,1,UN,47.85,47.85,3.83,47.85,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.07,,,percent of total billed charges,,,,,,,,,47.85,,,percent of total billed charges,,,26.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,24.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.6,,,percent of total billed charges,,
OXACILLIN  SOD 1 GM,2500002520,CDM,636,RC,J2700,HCPCS,5515012715,NDC,,,,outpatient,facility,1,UN,47.85,47.85,0.98,618.77,,27.94,,,percent of total billed charges,,,9.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,47.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,43.07,,,percent of total billed charges,,,,,,,,,47.85,,,percent of total billed charges,,,32.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.95,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,18.13,,,percent of total billed charges,,,24.78,,,percent of total billed charges,,,,,,,,,,,,,,,9.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,47.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,47.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.83,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,,,,,,,47.85,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.98,,,fee schedule,,,47.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,33.6,,,percent of total billed charges,,
OXACILLIN  SOD 1 GM,2500002520,CDM,636,RC,J2700,HCPCS,5515012715,NDC,496,EAPG,,outpatient,facility,1,UN,47.85,47.85,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXACILLIN  SOD INJ 2 GM,2500002522,CDM,636,RC,J2700,HCPCS,5515012824,NDC,,,,inpatient,facility,2,UN,93.32,93.32,7.47,93.32,,,,,,,,,,,,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.99,,,percent of total billed charges,,,,,,,,,93.32,,,percent of total billed charges,,,51.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,93.32,,,percent of total billed charges,,,48.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,percent of total billed charges,,,93.32,,,percent of total billed charges,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.53,,,percent of total billed charges,,
OXACILLIN  SOD INJ 2 GM,2500002522,CDM,636,RC,J2700,HCPCS,5515012824,NDC,,,,outpatient,facility,2,UN,93.32,93.32,0.98,618.77,,54.5,,,percent of total billed charges,,,18.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,93.32,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,34.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,83.99,,,percent of total billed charges,,,,,,,,,93.32,,,percent of total billed charges,,,63.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.66,,,percent of total billed charges,,,93.32,,,percent of total billed charges,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.92,,,percent of total billed charges,,,35.35,,,percent of total billed charges,,,48.33,,,percent of total billed charges,,,,,,,,,,,,,,,18.66,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,93.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,93.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.47,,,percent of total billed charges,,,93.32,,,percent of total billed charges,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,93.32,,,percent of total billed charges,,,93.32,,,percent of total billed charges,,,,,,,,,93.32,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.98,,,fee schedule,,,93.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,93.32,,,percent of total billed charges,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,65.53,,,percent of total billed charges,,
OXACILLIN  SOD INJ 2 GM,2500002522,CDM,636,RC,J2700,HCPCS,5515012824,NDC,496,EAPG,,outpatient,facility,2,UN,93.32,93.32,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOSTIGMINE 1MG/1ML 5ML SYR,2500002535,CDM,636,RC,J2710,HCPCS,7128660651,NDC,,,,inpatient,facility,5,UN,148.5,148.5,11.88,148.5,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.65,,,percent of total billed charges,,,,,,,,,148.5,,,percent of total billed charges,,,82.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,77.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.28,,,percent of total billed charges,,
NEOSTIGMINE 1MG/1ML 5ML SYR,2500002535,CDM,636,RC,J2710,HCPCS,7128660651,NDC,,,,outpatient,facility,5,UN,148.5,148.5,0.43,618.77,,86.72,,,percent of total billed charges,,,28.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,148.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,54.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,133.65,,,percent of total billed charges,,,,,,,,,148.5,,,percent of total billed charges,,,100.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.43,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.86,,,percent of total billed charges,,,56.25,,,percent of total billed charges,,,76.91,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,148.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,148.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.88,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,,,,,,,148.5,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.43,,,fee schedule,,,148.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,148.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,104.28,,,percent of total billed charges,,
NEOSTIGMINE 1MG/1ML 5ML SYR,2500002535,CDM,636,RC,J2710,HCPCS,7128660651,NDC,999,EAPG,,outpatient,facility,5,UN,148.5,148.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROTAMINE SULF INJ  50 MG,2500002542,CDM,636,RC,J2720,HCPCS,6332322905,NDC,,,,inpatient,facility,5,UN,51.08,51.08,4.09,51.08,,,,,,,,,,,,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.97,,,percent of total billed charges,,,,,,,,,51.08,,,percent of total billed charges,,,28.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,51.08,,,percent of total billed charges,,,26.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,51.08,,,percent of total billed charges,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.87,,,percent of total billed charges,,
PROTAMINE SULF INJ  50 MG,2500002542,CDM,636,RC,J2720,HCPCS,6332322905,NDC,,,,outpatient,facility,5,UN,51.08,51.08,0.92,618.77,,29.83,,,percent of total billed charges,,,9.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,51.08,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,18.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,45.97,,,percent of total billed charges,,,,,,,,,51.08,,,percent of total billed charges,,,34.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.63,,,percent of total billed charges,,,51.08,,,percent of total billed charges,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.82,,,percent of total billed charges,,,19.35,,,percent of total billed charges,,,26.45,,,percent of total billed charges,,,,,,,,,,,,,,,10.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,51.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.09,,,percent of total billed charges,,,51.08,,,percent of total billed charges,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,51.08,,,percent of total billed charges,,,51.08,,,percent of total billed charges,,,,,,,,,51.08,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.92,,,fee schedule,,,51.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,51.08,,,percent of total billed charges,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.87,,,percent of total billed charges,,
PROTAMINE SULF INJ  50 MG,2500002542,CDM,636,RC,J2720,HCPCS,6332322905,NDC,999,EAPG,,outpatient,facility,5,UN,51.08,51.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENTOLAMINE INJ UP TO 5 MG,2500002570,CDM,636,RC,J2760,HCPCS,6809410120,NDC,,,,inpatient,facility,5,UN,1662.41,1662.41,132.99,1662.41,,,,,,,,,,,,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1496.17,,,percent of total billed charges,,,,,,,,,1662.41,,,percent of total billed charges,,,920.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1516.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,1662.41,,,percent of total billed charges,,,866.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.99,,,percent of total billed charges,,,1662.41,,,percent of total billed charges,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1167.34,,,percent of total billed charges,,
PHENTOLAMINE INJ UP TO 5 MG,2500002570,CDM,636,RC,J2760,HCPCS,6809410120,NDC,,,,outpatient,facility,5,UN,1662.41,1662.41,132.99,1662.41,,970.85,,,percent of total billed charges,,,,,,,,,1662.41,,,percent of total billed charges,,,472.01,,,fee schedule,,,454.84,,,fee schedule,,,,,,,,,454.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1496.17,,,percent of total billed charges,,,,,,,,,1662.41,,,percent of total billed charges,,,1125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276.73,,,percent of total billed charges,,,,,,,,,,,,,,,446.8,,,fee schedule,,,446.8,,,fee schedule,,,,,,,,,618.77,,,per diem,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,866.78,,,percent of total billed charges,,,1662.41,,,percent of total billed charges,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1263.43,,,percent of total billed charges,,,629.72,,,percent of total billed charges,,,860.96,,,percent of total billed charges,,,,,,,,,,,,,,,332.48,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,912.53,,,fee schedule,,,406.85,,,fee schedule,,,,,,,,,,,,,,,132.99,,,percent of total billed charges,,,1662.41,,,percent of total billed charges,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,1662.41,,,percent of total billed charges,,,1662.41,,,percent of total billed charges,,,,,,,,,1662.41,,,fee schedule,,,434.14,,,fee schedule,,,,,,,,,,,,,,,381.77,,,fee schedule,,,509.02,,,fee schedule,,,282.19,,,fee schedule,,,414.4,,,fee schedule,,,1662.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1662.41,,,percent of total billed charges,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,831.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1167.34,,,percent of total billed charges,,
PHENTOLAMINE INJ UP TO 5 MG,2500002570,CDM,636,RC,J2760,HCPCS,6809410120,NDC,1458,APC,,outpatient,facility,5,UN,1662.41,1662.41,367.12,608.44,,,,,,,,406.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,394.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.58,,,fee schedule,,,,,,,,,608.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,394.63,,,fee schedule,,,,,,,,,,,,,,,394.63,,,fee schedule,,,414.36,,,fee schedule,,,,,,,,,394.63,,,fee schedule,,,394.63,,,fee schedule,,,414.36,,,fee schedule,,,,,,,,,,,,,,,572.21,,,fee schedule,,,,,,,,,,,,,,,394.63,,,fee schedule,,,,,,,,,,,,,,,378.84,,,fee schedule,,,422.25,,,fee schedule,,,414.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,394.63,,,fee schedule,,,394.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,410.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,493.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,493.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,394.63,,,fee schedule,,,394.63,,,fee schedule,,,,,,,,,,,,,,,394.63,,,fee schedule,,,,,,,,,,,,,,,394.63,,,fee schedule,,,406.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,367.12,,,fee schedule,,,394.63,,,fee schedule,,,410.42,,,fee schedule,,,394.63,,,fee schedule,,,,,,,,,394.63,,,fee schedule,,,,,,,,,394.63,,,fee schedule,,,,,,,,
PHENTOLAMINE INJ UP TO 5 MG,2500002570,CDM,636,RC,J2760,HCPCS,6809410120,NDC,437,EAPG,,outpatient,facility,5,UN,1662.41,1662.41,151.7,222.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.39,,,fee schedule,,,151.7,,,fee schedule,,,197.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,151.7,,,fee schedule,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOCLOPRAMIDE INJ 10 MG,2500002580,CDM,636,RC,J2765,HCPCS,409341401,NDC,,,,inpatient,facility,2,ML,4.09,4.09,0.33,4.09,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,,,,,,,4.09,,,percent of total billed charges,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,
METOCLOPRAMIDE INJ 10 MG,2500002580,CDM,636,RC,J2765,HCPCS,409341401,NDC,,,,outpatient,facility,2,ML,4.09,4.09,0.33,618.77,,2.39,,,percent of total billed charges,,,0.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.09,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.68,,,percent of total billed charges,,,,,,,,,4.09,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.11,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,4.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.33,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,4.09,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.96,,,fee schedule,,,4.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.87,,,percent of total billed charges,,
METOCLOPRAMIDE INJ 10 MG,2500002580,CDM,636,RC,J2765,HCPCS,409341401,NDC,999,EAPG,,outpatient,facility,2,ML,4.09,4.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.9  SD INJ 10ML,2500002650,CDM,250,RC,6332318610,NDC,,,,,,inpatient,facility,10,UN,3.36,3.36,0.27,3.36,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.02,,,percent of total billed charges,,,,,,,,,3.36,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,
SOD CHLORIDE 0.9  SD INJ 10ML,2500002650,CDM,250,RC,6332318610,NDC,,,,,,outpatient,facility,10,UN,3.36,3.36,0.27,618.77,,1.96,,,percent of total billed charges,,,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.36,,,percent of total billed charges,,,2.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.02,,,percent of total billed charges,,,,,,,,,3.36,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.34,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,3.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.27,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,3.36,,,fee schedule,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,3.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.36,,,percent of total billed charges,,
SOD CHLORIDE 0.9  SD INJ 10ML,2500002650,CDM,250,RC,6332318610,NDC,999,EAPG,,,,outpatient,facility,10,UN,3.36,3.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPRED SOD SUC 40 MG,2500002660,CDM,636,RC,J2919,HCPCS,9003928,NDC,,,,inpatient,facility,1,UN,21.35,21.35,1.71,21.35,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.22,,,percent of total billed charges,,,,,,,,,21.35,,,percent of total billed charges,,,11.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,11.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.99,,,percent of total billed charges,,
METHYLPRED SOD SUC 40 MG,2500002660,CDM,636,RC,J2919,HCPCS,9003928,NDC,,,,outpatient,facility,1,UN,21.35,21.35,0.31,618.77,,12.47,,,percent of total billed charges,,,,,,,,,21.35,,,percent of total billed charges,,,0.35,,,fee schedule,,,0.34,,,fee schedule,,,,,,,,,0.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,19.22,,,percent of total billed charges,,,,,,,,,21.35,,,percent of total billed charges,,,14.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.4,,,percent of total billed charges,,,,,,,,,,,,,,,11.53,,,percent of total billed charges,,,11.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.13,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.23,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,11.06,,,percent of total billed charges,,,,,,,,,,,,,,,4.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.9,,,percent of total billed charges,,,7.9,,,percent of total billed charges,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,,,,,,,21.35,,,fee schedule,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,0.31,,,fee schedule,,,21.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,21.35,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,14.99,,,percent of total billed charges,,
METHYLPRED SOD SUC 40 MG,2500002660,CDM,636,RC,J2919,HCPCS,9003928,NDC,801,APC,,outpatient,facility,1,UN,21.35,21.35,0.26,7.81,,,,,,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,7.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,0.39,,,fee schedule,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.26,,,fee schedule,,,0.29,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,,,,,,
METHYLPRED SOD SUC 40 MG,2500002660,CDM,636,RC,J2919,HCPCS,9003928,NDC,496,EAPG,,outpatient,facility,1,UN,21.35,21.35,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPRED SOD SUC 1000 MG,2500002672,CDM,636,RC,J2919,HCPCS,6332326530,NDC,,,,inpatient,facility,1000,UN,112.93,112.93,9.03,112.93,,,,,,,,,,,,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.64,,,percent of total billed charges,,,,,,,,,112.93,,,percent of total billed charges,,,62.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,112.93,,,percent of total billed charges,,,58.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.03,,,percent of total billed charges,,,112.93,,,percent of total billed charges,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.3,,,percent of total billed charges,,
METHYLPRED SOD SUC 1000 MG,2500002672,CDM,636,RC,J2919,HCPCS,6332326530,NDC,,,,outpatient,facility,1000,UN,112.93,112.93,0.31,618.77,,65.95,,,percent of total billed charges,,,,,,,,,112.93,,,percent of total billed charges,,,0.35,,,fee schedule,,,0.34,,,fee schedule,,,,,,,,,0.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,101.64,,,percent of total billed charges,,,,,,,,,112.93,,,percent of total billed charges,,,76.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.73,,,percent of total billed charges,,,,,,,,,,,,,,,60.98,,,percent of total billed charges,,,60.98,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.88,,,percent of total billed charges,,,112.93,,,percent of total billed charges,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.83,,,percent of total billed charges,,,42.78,,,percent of total billed charges,,,58.49,,,percent of total billed charges,,,,,,,,,,,,,,,22.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,41.78,,,percent of total billed charges,,,41.78,,,percent of total billed charges,,,,,,,,,,,,,,,9.03,,,percent of total billed charges,,,112.93,,,percent of total billed charges,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,112.93,,,percent of total billed charges,,,112.93,,,percent of total billed charges,,,,,,,,,112.93,,,fee schedule,,,105.05,,,percent of total billed charges,,,,,,,,,,,,,,,105.05,,,percent of total billed charges,,,105.05,,,percent of total billed charges,,,105.05,,,percent of total billed charges,,,0.31,,,fee schedule,,,112.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,112.93,,,percent of total billed charges,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,79.3,,,percent of total billed charges,,
METHYLPRED SOD SUC 1000 MG,2500002672,CDM,636,RC,J2919,HCPCS,6332326530,NDC,801,APC,,outpatient,facility,1000,UN,112.93,112.93,0.26,41.33,,,,,,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,41.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,0.39,,,fee schedule,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.26,,,fee schedule,,,0.29,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,,,,,,
METHYLPRED SOD SUC 1000 MG,2500002672,CDM,636,RC,J2919,HCPCS,6332326530,NDC,496,EAPG,,outpatient,facility,1000,UN,112.93,112.93,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPRED SOD SUC 500 MG,2500002676,CDM,636,RC,J2919,HCPCS,143985001,NDC,,,,inpatient,facility,500,UN,76.3,76.3,6.1,76.3,,,,,,,,,,,,,,76.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.67,,,percent of total billed charges,,,,,,,,,76.3,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.3,,,percent of total billed charges,,,,,,,,,,,,,,,76.3,,,percent of total billed charges,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.1,,,percent of total billed charges,,,76.3,,,percent of total billed charges,,,76.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,76.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.58,,,percent of total billed charges,,
METHYLPRED SOD SUC 500 MG,2500002676,CDM,636,RC,J2919,HCPCS,143985001,NDC,,,,outpatient,facility,500,UN,76.3,76.3,0.31,618.77,,44.56,,,percent of total billed charges,,,,,,,,,76.3,,,percent of total billed charges,,,0.35,,,fee schedule,,,0.34,,,fee schedule,,,,,,,,,0.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,76.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,68.67,,,percent of total billed charges,,,,,,,,,76.3,,,percent of total billed charges,,,51.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.6,,,percent of total billed charges,,,,,,,,,,,,,,,41.2,,,percent of total billed charges,,,41.2,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,76.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,76.3,,,percent of total billed charges,,,76.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.99,,,percent of total billed charges,,,28.9,,,percent of total billed charges,,,39.52,,,percent of total billed charges,,,,,,,,,,,,,,,15.26,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,28.23,,,percent of total billed charges,,,28.23,,,percent of total billed charges,,,,,,,,,,,,,,,6.1,,,percent of total billed charges,,,76.3,,,percent of total billed charges,,,76.3,,,percent of total billed charges,,,,,,,,,,,,,,,76.3,,,percent of total billed charges,,,76.3,,,percent of total billed charges,,,,,,,,,76.3,,,fee schedule,,,70.97,,,percent of total billed charges,,,,,,,,,,,,,,,70.97,,,percent of total billed charges,,,70.97,,,percent of total billed charges,,,70.97,,,percent of total billed charges,,,0.31,,,fee schedule,,,76.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,76.3,,,percent of total billed charges,,,76.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,53.58,,,percent of total billed charges,,
METHYLPRED SOD SUC 500 MG,2500002676,CDM,636,RC,J2919,HCPCS,143985001,NDC,801,APC,,outpatient,facility,500,UN,76.3,76.3,0.26,27.93,,,,,,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,27.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,0.39,,,fee schedule,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.26,,,fee schedule,,,0.29,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,,,,,,
METHYLPRED SOD SUC 500 MG,2500002676,CDM,636,RC,J2919,HCPCS,143985001,NDC,496,EAPG,,outpatient,facility,500,UN,76.3,76.3,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL INJ  2 ML (0.1 MG),2500002740,CDM,636,RC,J3010,HCPCS,409909332,NDC,,,,inpatient,facility,2,ML,5.91,5.91,0.47,5.91,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.32,,,percent of total billed charges,,,,,,,,,5.91,,,percent of total billed charges,,,3.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,3.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.15,,,percent of total billed charges,,
FENTANYL INJ  2 ML (0.1 MG),2500002740,CDM,636,RC,J3010,HCPCS,409909332,NDC,,,,outpatient,facility,2,ML,5.91,5.91,0.47,618.77,,3.45,,,percent of total billed charges,,,1.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.91,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.32,,,percent of total billed charges,,,,,,,,,5.91,,,percent of total billed charges,,,4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.08,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.49,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,3.06,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,5.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.47,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,,,,,,,5.91,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.87,,,fee schedule,,,5.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.91,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.15,,,percent of total billed charges,,
FENTANYL INJ  2 ML (0.1 MG),2500002740,CDM,636,RC,J3010,HCPCS,409909332,NDC,496,EAPG,,outpatient,facility,2,ML,5.91,5.91,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL INJ   50ML (2.5 MG),2500002746,CDM,636,RC,J3010,HCPCS,409909461,NDC,,,,inpatient,facility,50,UN,71.84,71.84,5.75,71.84,,,,,,,,,,,,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.66,,,percent of total billed charges,,,,,,,,,71.84,,,percent of total billed charges,,,39.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,71.84,,,percent of total billed charges,,,37.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.75,,,percent of total billed charges,,,71.84,,,percent of total billed charges,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.45,,,percent of total billed charges,,
FENTANYL INJ   50ML (2.5 MG),2500002746,CDM,636,RC,J3010,HCPCS,409909461,NDC,,,,outpatient,facility,50,UN,71.84,71.84,0.87,618.77,,41.95,,,percent of total billed charges,,,14.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,71.84,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,26.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,64.66,,,percent of total billed charges,,,,,,,,,71.84,,,percent of total billed charges,,,48.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.46,,,percent of total billed charges,,,71.84,,,percent of total billed charges,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.6,,,percent of total billed charges,,,27.21,,,percent of total billed charges,,,37.21,,,percent of total billed charges,,,,,,,,,,,,,,,14.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,71.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,71.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.75,,,percent of total billed charges,,,71.84,,,percent of total billed charges,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,71.84,,,percent of total billed charges,,,71.84,,,percent of total billed charges,,,,,,,,,71.84,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.87,,,fee schedule,,,71.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,71.84,,,percent of total billed charges,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,50.45,,,percent of total billed charges,,
FENTANYL INJ   50ML (2.5 MG),2500002746,CDM,636,RC,J3010,HCPCS,409909461,NDC,496,EAPG,,outpatient,facility,50,UN,71.84,71.84,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUMATRIPTAN SUCC INJ 6 MG,2500002750,CDM,636,RC,J3030,HCPCS,5515017301,NDC,,,,inpatient,facility,0.5,UN,43.56,43.56,3.48,43.56,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.2,,,percent of total billed charges,,,,,,,,,43.56,,,percent of total billed charges,,,24.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,22.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.59,,,percent of total billed charges,,
SUMATRIPTAN SUCC INJ 6 MG,2500002750,CDM,636,RC,J3030,HCPCS,5515017301,NDC,,,,outpatient,facility,0.5,UN,43.56,43.56,3.48,618.77,,25.44,,,percent of total billed charges,,,8.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,43.56,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,15.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,39.2,,,percent of total billed charges,,,,,,,,,43.56,,,percent of total billed charges,,,29.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.71,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.11,,,percent of total billed charges,,,16.5,,,percent of total billed charges,,,22.56,,,percent of total billed charges,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,43.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.48,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,,,,,,,43.56,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,43.56,,,fee schedule,,,43.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,43.56,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,30.59,,,percent of total billed charges,,
SUMATRIPTAN SUCC INJ 6 MG,2500002750,CDM,636,RC,J3030,HCPCS,5515017301,NDC,435,EAPG,,outpatient,facility,0.5,UN,43.56,43.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TERBUTALINE SULF INJ 1 MG,2500002780,CDM,636,RC,J3105,HCPCS,143974610,NDC,,,,inpatient,facility,1,ML,13.2,13.2,1.06,13.2,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,6.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.27,,,percent of total billed charges,,
TERBUTALINE SULF INJ 1 MG,2500002780,CDM,636,RC,J3105,HCPCS,143974610,NDC,,,,outpatient,facility,1,ML,13.2,13.2,1.06,618.77,,7.71,,,percent of total billed charges,,,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.88,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.88,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,5,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,13.2,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.81,,,fee schedule,,,13.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.27,,,percent of total billed charges,,
TERBUTALINE SULF INJ 1 MG,2500002780,CDM,636,RC,J3105,HCPCS,143974610,NDC,999,EAPG,,outpatient,facility,1,ML,13.2,13.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORPROMAZINE 10 MG ORAL,2500002834,CDM,636,RC,Q0161,HCPCS,5026816215,NDC,,,,inpatient,facility,10,UN,16.96,16.96,1.36,16.96,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.26,,,percent of total billed charges,,,,,,,,,16.96,,,percent of total billed charges,,,9.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,8.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.91,,,percent of total billed charges,,
CHLORPROMAZINE 10 MG ORAL,2500002834,CDM,636,RC,Q0161,HCPCS,5026816215,NDC,,,,outpatient,facility,10,UN,16.96,16.96,1.36,618.77,,9.9,,,percent of total billed charges,,,3.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.96,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,15.26,,,percent of total billed charges,,,,,,,,,16.96,,,percent of total billed charges,,,11.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.84,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.89,,,percent of total billed charges,,,6.42,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,16.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.36,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,,,,,,,16.96,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,12.72,,,percent of total billed charges,,,16.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.96,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.91,,,percent of total billed charges,,
CHLORPROMAZINE 10 MG ORAL,2500002834,CDM,636,RC,Q0161,HCPCS,5026816215,NDC,999,EAPG,,outpatient,facility,10,UN,16.96,16.96,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORPROMAZINE 100 MG ORAL,2500002835,CDM,636,RC,Q0161,HCPCS,832030300,NDC,,,,inpatient,facility,100,UN,49.13,49.13,3.93,49.13,,,,,,,,,,,,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.22,,,percent of total billed charges,,,,,,,,,49.13,,,percent of total billed charges,,,27.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,49.13,,,percent of total billed charges,,,25.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.5,,,percent of total billed charges,,
CHLORPROMAZINE 100 MG ORAL,2500002835,CDM,636,RC,Q0161,HCPCS,832030300,NDC,,,,outpatient,facility,100,UN,49.13,49.13,3.93,618.77,,28.69,,,percent of total billed charges,,,9.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,49.13,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,44.22,,,percent of total billed charges,,,,,,,,,49.13,,,percent of total billed charges,,,33.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.62,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.34,,,percent of total billed charges,,,18.61,,,percent of total billed charges,,,25.44,,,percent of total billed charges,,,,,,,,,,,,,,,9.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,49.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,49.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.93,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,49.13,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,,,,,,,49.13,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,36.85,,,percent of total billed charges,,,49.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,49.13,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,34.5,,,percent of total billed charges,,
CHLORPROMAZINE 100 MG ORAL,2500002835,CDM,636,RC,Q0161,HCPCS,832030300,NDC,999,EAPG,,outpatient,facility,100,UN,49.13,49.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORPROMAZINE 25 MG ORAL,2500002836,CDM,637,RC,Q0161,HCPCS,1671404801,NDC,,,,inpatient,facility,25,UN,24.55,24.55,1.96,24.55,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.1,,,percent of total billed charges,,,,,,,,,24.55,,,percent of total billed charges,,,13.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,12.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.24,,,percent of total billed charges,,
CHLORPROMAZINE 25 MG ORAL,2500002836,CDM,637,RC,Q0161,HCPCS,1671404801,NDC,,,,outpatient,facility,25,UN,24.55,24.55,1.96,618.77,,14.34,,,percent of total billed charges,,,4.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,24.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22.1,,,percent of total billed charges,,,,,,,,,24.55,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.8,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.66,,,percent of total billed charges,,,9.3,,,percent of total billed charges,,,12.71,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,24.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.96,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,24.55,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,18.41,,,percent of total billed charges,,,24.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.24,,,percent of total billed charges,,
CHLORPROMAZINE 25 MG ORAL,2500002836,CDM,637,RC,Q0161,HCPCS,1671404801,NDC,999,EAPG,,outpatient,facility,25,UN,24.55,24.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TOBRAMYCIN SULF INJ PER 80 MG,2500002860,CDM,636,RC,J3260,HCPCS,6745747322,NDC,,,,inpatient,facility,2,UN,7.85,7.85,0.63,7.85,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.06,,,percent of total billed charges,,,,,,,,,7.85,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,
TOBRAMYCIN SULF INJ PER 80 MG,2500002860,CDM,636,RC,J3260,HCPCS,6745747322,NDC,,,,outpatient,facility,2,UN,7.85,7.85,0.63,618.77,,4.58,,,percent of total billed charges,,,1.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.06,,,percent of total billed charges,,,,,,,,,7.85,,,percent of total billed charges,,,5.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,4.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,7.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.63,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,7.85,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.48,,,fee schedule,,,7.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.85,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.51,,,percent of total billed charges,,
TOBRAMYCIN SULF INJ PER 80 MG,2500002860,CDM,636,RC,J3260,HCPCS,6745747322,NDC,999,EAPG,,outpatient,facility,2,UN,7.85,7.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATOMOXETINE 10 MG CAP,2500002867,CDM,637,RC,6846226530,NDC,,,,,,inpatient,facility,10,UN,46.95,46.95,3.76,46.95,,,,,,,,,,,,,,46.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.26,,,percent of total billed charges,,,,,,,,,46.95,,,percent of total billed charges,,,25.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.95,,,percent of total billed charges,,,,,,,,,,,,,,,46.95,,,percent of total billed charges,,,24.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,46.95,,,percent of total billed charges,,,46.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.97,,,percent of total billed charges,,
ATOMOXETINE 10 MG CAP,2500002867,CDM,637,RC,6846226530,NDC,,,,,,outpatient,facility,10,UN,46.95,46.95,3.76,618.77,,27.42,,,percent of total billed charges,,,9.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,46.95,,,percent of total billed charges,,,41.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,41.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,41.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,42.26,,,percent of total billed charges,,,,,,,,,46.95,,,percent of total billed charges,,,31.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.06,,,percent of total billed charges,,,,,,,,,,,,,,,25.35,,,percent of total billed charges,,,25.35,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,46.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.48,,,percent of total billed charges,,,46.95,,,percent of total billed charges,,,46.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.68,,,percent of total billed charges,,,17.78,,,percent of total billed charges,,,24.32,,,percent of total billed charges,,,,,,,,,,,,,,,9.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,17.37,,,percent of total billed charges,,,17.37,,,percent of total billed charges,,,46.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.76,,,percent of total billed charges,,,46.95,,,percent of total billed charges,,,46.95,,,percent of total billed charges,,,,,,,,,,,,,,,46.95,,,percent of total billed charges,,,46.95,,,percent of total billed charges,,,,,,,,,46.95,,,fee schedule,,,43.67,,,percent of total billed charges,,,,,,,,,,,,,,,43.67,,,percent of total billed charges,,,43.67,,,percent of total billed charges,,,43.67,,,percent of total billed charges,,,35.21,,,percent of total billed charges,,,46.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,46.95,,,percent of total billed charges,,,46.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,32.97,,,percent of total billed charges,,
ATOMOXETINE 10 MG CAP,2500002867,CDM,637,RC,6846226530,NDC,999,EAPG,,,,outpatient,facility,10,UN,46.95,46.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIAMCINOLONE ACET INJ NOS 10,2500002900,CDM,636,RC,J3301,HCPCS,3049420,NDC,,,,inpatient,facility,5,GR,39.9,39.9,3.19,39.9,,,,,,,,,,,,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.91,,,percent of total billed charges,,,,,,,,,39.9,,,percent of total billed charges,,,22.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,39.9,,,percent of total billed charges,,,20.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.02,,,percent of total billed charges,,
TRIAMCINOLONE ACET INJ NOS 10,2500002900,CDM,636,RC,J3301,HCPCS,3049420,NDC,,,,outpatient,facility,5,GR,39.9,39.9,1.07,618.77,,23.3,,,percent of total billed charges,,,7.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,39.9,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,14.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,35.91,,,percent of total billed charges,,,,,,,,,39.9,,,percent of total billed charges,,,27.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.8,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.32,,,percent of total billed charges,,,15.11,,,percent of total billed charges,,,20.66,,,percent of total billed charges,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,39.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,39.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.19,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,39.9,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,39.9,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.07,,,fee schedule,,,39.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,39.9,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,28.02,,,percent of total billed charges,,
TRIAMCINOLONE ACET INJ NOS 10,2500002900,CDM,636,RC,J3301,HCPCS,3049420,NDC,496,EAPG,,outpatient,facility,5,GR,39.9,39.9,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIAMCINOLONE ACET INJ 40 MG,2500002906,CDM,636,RC,J3301,HCPCS,703024101,NDC,,,,inpatient,facility,1,ML,32.04,32.04,2.56,32.04,,,,,,,,,,,,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.84,,,percent of total billed charges,,,,,,,,,32.04,,,percent of total billed charges,,,17.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,32.04,,,percent of total billed charges,,,16.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.5,,,percent of total billed charges,,
TRIAMCINOLONE ACET INJ 40 MG,2500002906,CDM,636,RC,J3301,HCPCS,703024101,NDC,,,,outpatient,facility,1,ML,32.04,32.04,1.07,618.77,,18.71,,,percent of total billed charges,,,6.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,32.04,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,28.84,,,percent of total billed charges,,,,,,,,,32.04,,,percent of total billed charges,,,21.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.71,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.35,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,16.59,,,percent of total billed charges,,,,,,,,,,,,,,,6.41,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,32.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.56,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,32.04,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,,,,,,,32.04,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.07,,,fee schedule,,,32.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,32.04,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,22.5,,,percent of total billed charges,,
TRIAMCINOLONE ACET INJ 40 MG,2500002906,CDM,636,RC,J3301,HCPCS,703024101,NDC,496,EAPG,,outpatient,facility,1,ML,32.04,32.04,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPINEPHrine/NS 8 MG/250 ML BAG,2500002908,CDM,636,RC,J0171,HCPCS,7101907101,NDC,,,,inpatient,facility,250,UN,314.75,314.75,25.18,314.75,,,,,,,,,,,,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.28,,,percent of total billed charges,,,,,,,,,314.75,,,percent of total billed charges,,,174.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,314.75,,,percent of total billed charges,,,164.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,314.75,,,percent of total billed charges,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.02,,,percent of total billed charges,,
EPINEPHrine/NS 8 MG/250 ML BAG,2500002908,CDM,636,RC,J0171,HCPCS,7101907101,NDC,,,,outpatient,facility,250,UN,314.75,314.75,0.84,618.77,,183.81,,,percent of total billed charges,,,61.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,314.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,115.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,283.28,,,percent of total billed charges,,,,,,,,,314.75,,,percent of total billed charges,,,213.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.11,,,percent of total billed charges,,,314.75,,,percent of total billed charges,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.21,,,percent of total billed charges,,,119.23,,,percent of total billed charges,,,163.01,,,percent of total billed charges,,,,,,,,,,,,,,,62.95,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,314.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,314.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.18,,,percent of total billed charges,,,314.75,,,percent of total billed charges,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,314.75,,,percent of total billed charges,,,314.75,,,percent of total billed charges,,,,,,,,,314.75,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.84,,,fee schedule,,,314.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,314.75,,,percent of total billed charges,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,221.02,,,percent of total billed charges,,
EPINEPHrine/NS 8 MG/250 ML BAG,2500002908,CDM,636,RC,J0171,HCPCS,7101907101,NDC,496,EAPG,,outpatient,facility,250,UN,314.75,314.75,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REMDESIVIR 100 MG/20 ML INJ,2500002921,CDM,636,RC,J0248,HCPCS,6195829021,NDC,,,,inpatient,facility,20,UN,1716,1716,137.28,1716,,,,,,,,,,,,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1544.4,,,percent of total billed charges,,,,,,,,,1716,,,percent of total billed charges,,,949.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1565.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,1716,,,percent of total billed charges,,,894.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,343.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,,1716,,,percent of total billed charges,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1204.98,,,percent of total billed charges,,
REMDESIVIR 100 MG/20 ML INJ,2500002921,CDM,636,RC,J0248,HCPCS,6195829021,NDC,,,,outpatient,facility,20,UN,1716,1716,3.76,1716,,1002.14,,,percent of total billed charges,,,,,,,,,1716,,,percent of total billed charges,,,6.51,,,fee schedule,,,6.28,,,fee schedule,,,,,,,,,6.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1544.4,,,percent of total billed charges,,,,,,,,,1716,,,percent of total billed charges,,,1162.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1317.89,,,percent of total billed charges,,,,,,,,,,,,,,,6.06,,,fee schedule,,,6.06,,,fee schedule,,,,,,,,,618.77,,,per diem,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,894.72,,,percent of total billed charges,,,1716,,,percent of total billed charges,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.16,,,percent of total billed charges,,,650.02,,,percent of total billed charges,,,888.72,,,percent of total billed charges,,,,,,,,,,,,,,,343.2,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,12.16,,,fee schedule,,,5.42,,,fee schedule,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,,1716,,,percent of total billed charges,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,1716,,,percent of total billed charges,,,1716,,,percent of total billed charges,,,,,,,,,1716,,,fee schedule,,,5.79,,,fee schedule,,,,,,,,,,,,,,,4.34,,,fee schedule,,,5.79,,,fee schedule,,,3.76,,,fee schedule,,,6.59,,,fee schedule,,,1716,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1716,,,percent of total billed charges,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,858,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1204.98,,,percent of total billed charges,,
REMDESIVIR 100 MG/20 ML INJ,2500002921,CDM,636,RC,J0248,HCPCS,6195829021,NDC,9200,APC,,outpatient,facility,20,UN,1716,1716,6.1,628.06,,,,,,,,6.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.41,,,fee schedule,,,,,,,,,628.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,6.35,,,fee schedule,,,,,,,,,,,,,,,6.35,,,fee schedule,,,6.67,,,fee schedule,,,,,,,,,6.35,,,fee schedule,,,6.35,,,fee schedule,,,6.67,,,fee schedule,,,,,,,,,,,,,,,9.21,,,fee schedule,,,,,,,,,,,,,,,6.35,,,fee schedule,,,,,,,,,,,,,,,6.1,,,fee schedule,,,6.79,,,fee schedule,,,6.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.35,,,fee schedule,,,6.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.35,,,fee schedule,,,6.35,,,fee schedule,,,,,,,,,,,,,,,6.35,,,fee schedule,,,,,,,,,,,,,,,6.35,,,fee schedule,,,6.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.35,,,fee schedule,,,6.35,,,fee schedule,,,6.6,,,fee schedule,,,6.35,,,fee schedule,,,,,,,,,6.35,,,fee schedule,,,,,,,,,6.35,,,fee schedule,,,,,,,,
REMDESIVIR 100 MG/20 ML INJ,2500002921,CDM,636,RC,J0248,HCPCS,6195829021,NDC,439,EAPG,,outpatient,facility,20,UN,1716,1716,767.47,1125.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.11,,,fee schedule,,,767.47,,,fee schedule,,,1000.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,767.47,,,fee schedule,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
UREA 15 GM PWD PKT,2500002964,CDM,637,RC,6253000011,NDC,,,,,,inpatient,facility,15,UN,11.98,11.98,0.96,11.98,,,,,,,,,,,,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.78,,,percent of total billed charges,,,,,,,,,11.98,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,,11.98,,,percent of total billed charges,,,6.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,11.98,,,percent of total billed charges,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.41,,,percent of total billed charges,,
UREA 15 GM PWD PKT,2500002964,CDM,637,RC,6253000011,NDC,,,,,,outpatient,facility,15,UN,11.98,11.98,0.96,618.77,,7,,,percent of total billed charges,,,2.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.98,,,percent of total billed charges,,,10.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,10.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,10.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.78,,,percent of total billed charges,,,,,,,,,11.98,,,percent of total billed charges,,,8.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.2,,,percent of total billed charges,,,,,,,,,,,,,,,6.47,,,percent of total billed charges,,,6.47,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.25,,,percent of total billed charges,,,11.98,,,percent of total billed charges,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.1,,,percent of total billed charges,,,4.54,,,percent of total billed charges,,,6.2,,,percent of total billed charges,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.43,,,percent of total billed charges,,,4.43,,,percent of total billed charges,,,11.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.96,,,percent of total billed charges,,,11.98,,,percent of total billed charges,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,,11.98,,,percent of total billed charges,,,11.98,,,percent of total billed charges,,,,,,,,,11.98,,,fee schedule,,,11.14,,,percent of total billed charges,,,,,,,,,,,,,,,11.14,,,percent of total billed charges,,,11.14,,,percent of total billed charges,,,11.14,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,11.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.98,,,percent of total billed charges,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.41,,,percent of total billed charges,,
UREA 15 GM PWD PKT,2500002964,CDM,637,RC,6253000011,NDC,999,EAPG,,,,outpatient,facility,15,UN,11.98,11.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMIODARONE 450 MG INJ,2500002969,CDM,636,RC,6332361609,NDC,,,,,,inpatient,facility,9,UN,18.05,18.05,1.44,18.05,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.25,,,percent of total billed charges,,,,,,,,,18.05,,,percent of total billed charges,,,9.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,9.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.67,,,percent of total billed charges,,
AMIODARONE 450 MG INJ,2500002969,CDM,636,RC,6332361609,NDC,,,,,,outpatient,facility,9,UN,18.05,18.05,1.44,618.77,,10.54,,,percent of total billed charges,,,3.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,18.05,,,percent of total billed charges,,,15.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,15.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,15.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,16.25,,,percent of total billed charges,,,,,,,,,18.05,,,percent of total billed charges,,,12.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.86,,,percent of total billed charges,,,,,,,,,,,,,,,9.75,,,percent of total billed charges,,,9.75,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.41,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,9.35,,,percent of total billed charges,,,,,,,,,,,,,,,3.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.22,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,18.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.44,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,18.05,,,fee schedule,,,7.22,,,percent of total billed charges,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,13.54,,,percent of total billed charges,,,18.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,12.67,,,percent of total billed charges,,
AMIODARONE 450 MG INJ,2500002969,CDM,636,RC,6332361609,NDC,999,EAPG,,,,outpatient,facility,9,UN,18.05,18.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIAZEPAM INJ 10MG,2500002972,CDM,636,RC,J3360,HCPCS,409127332,NDC,,,,inpatient,facility,2,UN,111.08,111.08,8.89,111.08,,,,,,,,,,,,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.97,,,percent of total billed charges,,,,,,,,,111.08,,,percent of total billed charges,,,61.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,111.08,,,percent of total billed charges,,,57.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.89,,,percent of total billed charges,,,111.08,,,percent of total billed charges,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78,,,percent of total billed charges,,
DIAZEPAM INJ 10MG,2500002972,CDM,636,RC,J3360,HCPCS,409127332,NDC,,,,outpatient,facility,2,UN,111.08,111.08,5.65,618.77,,64.87,,,percent of total billed charges,,,21.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,111.08,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,40.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,99.97,,,percent of total billed charges,,,,,,,,,111.08,,,percent of total billed charges,,,75.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,111.08,,,percent of total billed charges,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.42,,,percent of total billed charges,,,42.08,,,percent of total billed charges,,,57.53,,,percent of total billed charges,,,,,,,,,,,,,,,22.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,111.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,111.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.89,,,percent of total billed charges,,,111.08,,,percent of total billed charges,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,111.08,,,percent of total billed charges,,,111.08,,,percent of total billed charges,,,,,,,,,111.08,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,5.65,,,fee schedule,,,111.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,111.08,,,percent of total billed charges,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,78,,,percent of total billed charges,,
DIAZEPAM INJ 10MG,2500002972,CDM,636,RC,J3360,HCPCS,409127332,NDC,496,EAPG,,outpatient,facility,2,UN,111.08,111.08,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 1250 MG IV,2500002994,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,inpatient,facility,250,UN,79.6,79.6,6.37,79.6,,,,,,,,,,,,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.64,,,percent of total billed charges,,,,,,,,,79.6,,,percent of total billed charges,,,44.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,79.6,,,percent of total billed charges,,,41.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.37,,,percent of total billed charges,,,79.6,,,percent of total billed charges,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.9,,,percent of total billed charges,,
VANCOMYCIN 1250 MG IV,2500002994,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,outpatient,facility,250,UN,79.6,79.6,2.07,618.77,,46.49,,,percent of total billed charges,,,15.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,79.6,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,29.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,71.64,,,percent of total billed charges,,,,,,,,,79.6,,,percent of total billed charges,,,53.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.5,,,percent of total billed charges,,,79.6,,,percent of total billed charges,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.5,,,percent of total billed charges,,,30.15,,,percent of total billed charges,,,41.22,,,percent of total billed charges,,,,,,,,,,,,,,,15.92,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,79.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,79.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.37,,,percent of total billed charges,,,79.6,,,percent of total billed charges,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,79.6,,,percent of total billed charges,,,79.6,,,percent of total billed charges,,,,,,,,,79.6,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.07,,,fee schedule,,,79.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,79.6,,,percent of total billed charges,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,55.9,,,percent of total billed charges,,
VANCOMYCIN 1250 MG IV,2500002994,CDM,636,RC,J3370,HCPCS,6745734001,NDC,496,EAPG,,outpatient,facility,250,UN,79.6,79.6,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 1500 MG IV,2500002995,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,inpatient,facility,500,UN,95.5,95.5,7.64,95.5,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.95,,,percent of total billed charges,,,,,,,,,95.5,,,percent of total billed charges,,,52.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,49.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,95.5,,,percent of total billed charges,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.06,,,percent of total billed charges,,
VANCOMYCIN 1500 MG IV,2500002995,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,outpatient,facility,500,UN,95.5,95.5,2.07,618.77,,55.77,,,percent of total billed charges,,,18.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,95.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,34.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,85.95,,,percent of total billed charges,,,,,,,,,95.5,,,percent of total billed charges,,,64.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.79,,,percent of total billed charges,,,95.5,,,percent of total billed charges,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.58,,,percent of total billed charges,,,36.18,,,percent of total billed charges,,,49.46,,,percent of total billed charges,,,,,,,,,,,,,,,19.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,95.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,95.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.64,,,percent of total billed charges,,,95.5,,,percent of total billed charges,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,95.5,,,percent of total billed charges,,,,,,,,,95.5,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.07,,,fee schedule,,,95.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,95.5,,,percent of total billed charges,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,67.06,,,percent of total billed charges,,
VANCOMYCIN 1500 MG IV,2500002995,CDM,636,RC,J3370,HCPCS,6745734001,NDC,496,EAPG,,outpatient,facility,500,UN,95.5,95.5,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 1750 MG IV,2500002996,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,inpatient,facility,500,UN,63.53,63.53,5.08,63.53,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.18,,,percent of total billed charges,,,,,,,,,63.53,,,percent of total billed charges,,,35.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,33.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.61,,,percent of total billed charges,,
VANCOMYCIN 1750 MG IV,2500002996,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,outpatient,facility,500,UN,63.53,63.53,2.07,618.77,,37.1,,,percent of total billed charges,,,12.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,63.53,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,23.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,57.18,,,percent of total billed charges,,,,,,,,,63.53,,,percent of total billed charges,,,43.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.12,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.28,,,percent of total billed charges,,,24.07,,,percent of total billed charges,,,32.9,,,percent of total billed charges,,,,,,,,,,,,,,,12.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,63.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,63.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.08,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,,,,,,,63.53,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.07,,,fee schedule,,,63.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,63.53,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,44.61,,,percent of total billed charges,,
VANCOMYCIN 1750 MG IV,2500002996,CDM,636,RC,J3370,HCPCS,6745734001,NDC,496,EAPG,,outpatient,facility,500,UN,63.53,63.53,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 2000 MG IV,2500002997,CDM,636,RC,J3370,HCPCS,7207806699,NDC,,,,inpatient,facility,2000,UN,63.53,63.53,5.08,63.53,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.18,,,percent of total billed charges,,,,,,,,,63.53,,,percent of total billed charges,,,35.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,33.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.61,,,percent of total billed charges,,
VANCOMYCIN 2000 MG IV,2500002997,CDM,636,RC,J3370,HCPCS,7207806699,NDC,,,,outpatient,facility,2000,UN,63.53,63.53,2.07,618.77,,37.1,,,percent of total billed charges,,,12.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,63.53,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,23.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,57.18,,,percent of total billed charges,,,,,,,,,63.53,,,percent of total billed charges,,,43.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.12,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.28,,,percent of total billed charges,,,24.07,,,percent of total billed charges,,,32.9,,,percent of total billed charges,,,,,,,,,,,,,,,12.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,63.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,63.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.08,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,,,,,,,63.53,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.07,,,fee schedule,,,63.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,63.53,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,44.61,,,percent of total billed charges,,
VANCOMYCIN 2000 MG IV,2500002997,CDM,636,RC,J3370,HCPCS,7207806699,NDC,496,EAPG,,outpatient,facility,2000,UN,63.53,63.53,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 500 MG INJ,2500003000,CDM,636,RC,J3370,HCPCS,6745733950,NDC,,,,inpatient,facility,500,UN,31.84,31.84,2.55,31.84,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.66,,,percent of total billed charges,,,,,,,,,31.84,,,percent of total billed charges,,,17.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.36,,,percent of total billed charges,,
VANCOMYCIN 500 MG INJ,2500003000,CDM,636,RC,J3370,HCPCS,6745733950,NDC,,,,outpatient,facility,500,UN,31.84,31.84,2.07,618.77,,18.59,,,percent of total billed charges,,,6.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,31.84,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,28.66,,,percent of total billed charges,,,,,,,,,31.84,,,percent of total billed charges,,,21.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.2,,,percent of total billed charges,,,12.06,,,percent of total billed charges,,,16.49,,,percent of total billed charges,,,,,,,,,,,,,,,6.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,31.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.55,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,,,,,,,31.84,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.07,,,fee schedule,,,31.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,31.84,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,22.36,,,percent of total billed charges,,
VANCOMYCIN 500 MG INJ,2500003000,CDM,636,RC,J3370,HCPCS,6745733950,NDC,496,EAPG,,outpatient,facility,500,UN,31.84,31.84,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 1 GM INJ,2500003002,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,inpatient,facility,1000,UN,63.52,63.52,5.08,63.52,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.17,,,percent of total billed charges,,,,,,,,,63.52,,,percent of total billed charges,,,35.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,33.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,63.52,,,percent of total billed charges,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.6,,,percent of total billed charges,,
VANCOMYCIN 1 GM INJ,2500003002,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,outpatient,facility,1000,UN,63.52,63.52,2.07,618.77,,37.1,,,percent of total billed charges,,,12.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,63.52,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,23.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,57.17,,,percent of total billed charges,,,,,,,,,63.52,,,percent of total billed charges,,,43.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.12,,,percent of total billed charges,,,63.52,,,percent of total billed charges,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.28,,,percent of total billed charges,,,24.06,,,percent of total billed charges,,,32.9,,,percent of total billed charges,,,,,,,,,,,,,,,12.7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,63.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,63.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.08,,,percent of total billed charges,,,63.52,,,percent of total billed charges,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,63.52,,,percent of total billed charges,,,,,,,,,63.52,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.07,,,fee schedule,,,63.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,63.52,,,percent of total billed charges,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,44.6,,,percent of total billed charges,,
VANCOMYCIN 1 GM INJ,2500003002,CDM,636,RC,J3370,HCPCS,6745734001,NDC,496,EAPG,,outpatient,facility,1000,UN,63.52,63.52,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN HCL 750 MG INJ,2500003005,CDM,636,RC,J3370,HCPCS,338358048,NDC,,,,inpatient,facility,250,UN,38.38,38.38,3.07,38.38,,,,,,,,,,,,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.54,,,percent of total billed charges,,,,,,,,,38.38,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,38.38,,,percent of total billed charges,,,20.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.95,,,percent of total billed charges,,
VANCOMYCIN HCL 750 MG INJ,2500003005,CDM,636,RC,J3370,HCPCS,338358048,NDC,,,,outpatient,facility,250,UN,38.38,38.38,2.07,618.77,,22.41,,,percent of total billed charges,,,7.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,38.38,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,14.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,34.54,,,percent of total billed charges,,,,,,,,,38.38,,,percent of total billed charges,,,25.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.01,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.17,,,percent of total billed charges,,,14.54,,,percent of total billed charges,,,19.88,,,percent of total billed charges,,,,,,,,,,,,,,,7.68,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,38.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,38.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.07,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,38.38,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,,,,,,,38.38,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.07,,,fee schedule,,,38.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,38.38,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,26.95,,,percent of total billed charges,,
VANCOMYCIN HCL 750 MG INJ,2500003005,CDM,636,RC,J3370,HCPCS,338358048,NDC,496,EAPG,,outpatient,facility,250,UN,38.38,38.38,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROXYZINE INJ 50 MG/ML 1 ML,2500003032,CDM,636,RC,J3410,HCPCS,517560125,NDC,,,,inpatient,facility,1,UN,101.87,101.87,8.15,101.87,,,,,,,,,,,,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.68,,,percent of total billed charges,,,,,,,,,101.87,,,percent of total billed charges,,,56.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,101.87,,,percent of total billed charges,,,53.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,101.87,,,percent of total billed charges,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.53,,,percent of total billed charges,,
HYDROXYZINE INJ 50 MG/ML 1 ML,2500003032,CDM,636,RC,J3410,HCPCS,517560125,NDC,,,,outpatient,facility,1,UN,101.87,101.87,8.15,618.77,,59.49,,,percent of total billed charges,,,19.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,101.87,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,37.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,91.68,,,percent of total billed charges,,,,,,,,,101.87,,,percent of total billed charges,,,68.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.12,,,percent of total billed charges,,,101.87,,,percent of total billed charges,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.42,,,percent of total billed charges,,,38.59,,,percent of total billed charges,,,52.76,,,percent of total billed charges,,,,,,,,,,,,,,,20.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,101.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,101.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.15,,,percent of total billed charges,,,101.87,,,percent of total billed charges,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,101.87,,,percent of total billed charges,,,101.87,,,percent of total billed charges,,,,,,,,,101.87,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,15.05,,,fee schedule,,,101.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,101.87,,,percent of total billed charges,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,71.53,,,percent of total billed charges,,
HYDROXYZINE INJ 50 MG/ML 1 ML,2500003032,CDM,636,RC,J3410,HCPCS,517560125,NDC,496,EAPG,,outpatient,facility,1,UN,101.87,101.87,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VITAMIN B12 1000 MCG/ML INJ,2500003042,CDM,636,RC,J3420,HCPCS,6968011225,NDC,,,,inpatient,facility,1,UN,10.63,10.63,0.85,10.63,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.57,,,percent of total billed charges,,,,,,,,,10.63,,,percent of total billed charges,,,5.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.46,,,percent of total billed charges,,
VITAMIN B12 1000 MCG/ML INJ,2500003042,CDM,636,RC,J3420,HCPCS,6968011225,NDC,,,,outpatient,facility,1,UN,10.63,10.63,0.85,618.77,,6.21,,,percent of total billed charges,,,2.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.63,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.57,,,percent of total billed charges,,,,,,,,,10.63,,,percent of total billed charges,,,7.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.08,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,10.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.85,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,,,,,,,10.63,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.16,,,fee schedule,,,10.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.63,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.46,,,percent of total billed charges,,
VITAMIN B12 1000 MCG/ML INJ,2500003042,CDM,636,RC,J3420,HCPCS,6968011225,NDC,999,EAPG,,outpatient,facility,1,UN,10.63,10.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VITAMIN K PHYTONADIONE 10MG IN,2500003052,CDM,636,RC,J3430,HCPCS,4359840516,NDC,,,,inpatient,facility,1,UN,141.14,141.14,11.29,141.14,,,,,,,,,,,,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.03,,,percent of total billed charges,,,,,,,,,141.14,,,percent of total billed charges,,,78.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,141.14,,,percent of total billed charges,,,73.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.29,,,percent of total billed charges,,,141.14,,,percent of total billed charges,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.11,,,percent of total billed charges,,
VITAMIN K PHYTONADIONE 10MG IN,2500003052,CDM,636,RC,J3430,HCPCS,4359840516,NDC,,,,outpatient,facility,1,UN,141.14,141.14,2.96,618.77,,82.43,,,percent of total billed charges,,,27.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,141.14,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,51.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,127.03,,,percent of total billed charges,,,,,,,,,141.14,,,percent of total billed charges,,,95.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.59,,,percent of total billed charges,,,141.14,,,percent of total billed charges,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.27,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,73.1,,,percent of total billed charges,,,,,,,,,,,,,,,28.23,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,141.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,141.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.29,,,percent of total billed charges,,,141.14,,,percent of total billed charges,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,141.14,,,percent of total billed charges,,,141.14,,,percent of total billed charges,,,,,,,,,141.14,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.96,,,fee schedule,,,141.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,141.14,,,percent of total billed charges,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,99.11,,,percent of total billed charges,,
VITAMIN K PHYTONADIONE 10MG IN,2500003052,CDM,636,RC,J3430,HCPCS,4359840516,NDC,435,EAPG,,outpatient,facility,1,UN,141.14,141.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYALURONIDASE INJ 200 UNITS,2500003071,CDM,636,RC,J3471,HCPCS,2420800202,NDC,,,,inpatient,facility,1.2,UN,398.74,398.74,31.9,398.74,,,,,,,,,,,,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.87,,,percent of total billed charges,,,,,,,,,398.74,,,percent of total billed charges,,,220.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,398.74,,,percent of total billed charges,,,207.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.9,,,percent of total billed charges,,,398.74,,,percent of total billed charges,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280,,,percent of total billed charges,,
HYALURONIDASE INJ 200 UNITS,2500003071,CDM,636,RC,J3471,HCPCS,2420800202,NDC,,,,outpatient,facility,1.2,UN,398.74,398.74,0.52,618.77,,232.86,,,percent of total billed charges,,,77.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,398.74,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,145.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,358.87,,,percent of total billed charges,,,,,,,,,398.74,,,percent of total billed charges,,,270.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,207.9,,,percent of total billed charges,,,398.74,,,percent of total billed charges,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.04,,,percent of total billed charges,,,151.04,,,percent of total billed charges,,,206.51,,,percent of total billed charges,,,,,,,,,,,,,,,79.75,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,398.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,398.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.9,,,percent of total billed charges,,,398.74,,,percent of total billed charges,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,398.74,,,percent of total billed charges,,,398.74,,,percent of total billed charges,,,,,,,,,398.74,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.52,,,fee schedule,,,398.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,398.74,,,percent of total billed charges,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.37,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,280,,,percent of total billed charges,,
HYALURONIDASE INJ 200 UNITS,2500003071,CDM,636,RC,J3471,HCPCS,2420800202,NDC,436,EAPG,,outpatient,facility,1.2,UN,398.74,398.74,126.95,186.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.11,,,fee schedule,,,126.95,,,fee schedule,,,165.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGNESIUM SULF INJ 2 GM,2500003080,CDM,636,RC,J3475,HCPCS,409672924,NDC,,,,inpatient,facility,50,UN,53.46,53.46,4.28,53.46,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,,,,,,,53.46,,,percent of total billed charges,,,29.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,27.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.54,,,percent of total billed charges,,
MAGNESIUM SULF INJ 2 GM,2500003080,CDM,636,RC,J3475,HCPCS,409672924,NDC,,,,outpatient,facility,50,UN,53.46,53.46,0.52,618.77,,31.22,,,percent of total billed charges,,,10.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,53.46,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,19.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,48.11,,,percent of total billed charges,,,,,,,,,53.46,,,percent of total billed charges,,,36.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.87,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.63,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,10.69,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,53.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.28,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,53.46,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.52,,,fee schedule,,,53.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,37.54,,,percent of total billed charges,,
MAGNESIUM SULF INJ 2 GM,2500003080,CDM,636,RC,J3475,HCPCS,409672924,NDC,496,EAPG,,outpatient,facility,50,UN,53.46,53.46,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGNESIUM SULF INJ 1 GM (8MEQ),2500003081,CDM,636,RC,J3475,HCPCS,6332306403,NDC,,,,inpatient,facility,2,UN,6.57,6.57,0.53,6.57,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,,,,,,,6.57,,,percent of total billed charges,,,3.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.61,,,percent of total billed charges,,
MAGNESIUM SULF INJ 1 GM (8MEQ),2500003081,CDM,636,RC,J3475,HCPCS,6332306403,NDC,,,,outpatient,facility,2,UN,6.57,6.57,0.52,618.77,,3.84,,,percent of total billed charges,,,1.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.57,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.91,,,percent of total billed charges,,,,,,,,,6.57,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.99,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,6.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.53,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,,,,,,,6.57,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.52,,,fee schedule,,,6.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.57,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.61,,,percent of total billed charges,,
MAGNESIUM SULF INJ 1 GM (8MEQ),2500003081,CDM,636,RC,J3475,HCPCS,6332306403,NDC,496,EAPG,,outpatient,facility,2,UN,6.57,6.57,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGNESIUM SULF IV 1 GM/100 ML,2500003083,CDM,636,RC,J3475,HCPCS,338170940,NDC,,,,inpatient,facility,100,UN,21.09,21.09,1.69,21.09,,,,,,,,,,,,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.98,,,percent of total billed charges,,,,,,,,,21.09,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,21.09,,,percent of total billed charges,,,11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,21.09,,,percent of total billed charges,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.81,,,percent of total billed charges,,
MAGNESIUM SULF IV 1 GM/100 ML,2500003083,CDM,636,RC,J3475,HCPCS,338170940,NDC,,,,outpatient,facility,100,UN,21.09,21.09,0.52,618.77,,12.32,,,percent of total billed charges,,,4.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,21.09,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,18.98,,,percent of total billed charges,,,,,,,,,21.09,,,percent of total billed charges,,,14.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11,,,percent of total billed charges,,,21.09,,,percent of total billed charges,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.03,,,percent of total billed charges,,,7.99,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,21.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.69,,,percent of total billed charges,,,21.09,,,percent of total billed charges,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,21.09,,,percent of total billed charges,,,21.09,,,percent of total billed charges,,,,,,,,,21.09,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.52,,,fee schedule,,,21.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,21.09,,,percent of total billed charges,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,14.81,,,percent of total billed charges,,
MAGNESIUM SULF IV 1 GM/100 ML,2500003083,CDM,636,RC,J3475,HCPCS,338170940,NDC,496,EAPG,,outpatient,facility,100,UN,21.09,21.09,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGNESIUM SULF IV 4 GM/100 ML,2500003085,CDM,636,RC,J3475,HCPCS,409672923,NDC,,,,inpatient,facility,100,UN,26.5,26.5,2.12,26.5,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.85,,,percent of total billed charges,,,,,,,,,26.5,,,percent of total billed charges,,,14.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,13.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.61,,,percent of total billed charges,,
MAGNESIUM SULF IV 4 GM/100 ML,2500003085,CDM,636,RC,J3475,HCPCS,409672923,NDC,,,,outpatient,facility,100,UN,26.5,26.5,0.52,618.77,,15.48,,,percent of total billed charges,,,5.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,26.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,23.85,,,percent of total billed charges,,,,,,,,,26.5,,,percent of total billed charges,,,17.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.82,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.14,,,percent of total billed charges,,,10.04,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,5.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,26.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.12,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,,,,,,,26.5,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.52,,,fee schedule,,,26.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,26.5,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,18.61,,,percent of total billed charges,,
MAGNESIUM SULF IV 4 GM/100 ML,2500003085,CDM,636,RC,J3475,HCPCS,409672923,NDC,496,EAPG,,outpatient,facility,100,UN,26.5,26.5,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CL INJ 20 MEQ,2500003092,CDM,636,RC,J3480,HCPCS,6332396510,NDC,,,,inpatient,facility,10,UN,6.63,6.63,0.53,6.63,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,6.63,,,percent of total billed charges,,,3.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.66,,,percent of total billed charges,,
POTASSIUM CL INJ 20 MEQ,2500003092,CDM,636,RC,J3480,HCPCS,6332396510,NDC,,,,outpatient,facility,10,UN,6.63,6.63,0.11,618.77,,3.87,,,percent of total billed charges,,,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.63,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.97,,,percent of total billed charges,,,,,,,,,6.63,,,percent of total billed charges,,,4.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.04,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,6.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.53,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,,,,,,,6.63,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,6.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.63,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.66,,,percent of total billed charges,,
POTASSIUM CL INJ 20 MEQ,2500003092,CDM,636,RC,J3480,HCPCS,6332396510,NDC,999,EAPG,,outpatient,facility,10,UN,6.63,6.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CL INJ 40 MEQ,2500003094,CDM,636,RC,J3480,HCPCS,6332396520,NDC,,,,inpatient,facility,20,UN,7.59,7.59,0.61,7.59,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,,,,,,,7.59,,,percent of total billed charges,,,4.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.33,,,percent of total billed charges,,
POTASSIUM CL INJ 40 MEQ,2500003094,CDM,636,RC,J3480,HCPCS,6332396520,NDC,,,,outpatient,facility,20,UN,7.59,7.59,0.11,618.77,,4.43,,,percent of total billed charges,,,1.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.59,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.83,,,percent of total billed charges,,,,,,,,,7.59,,,percent of total billed charges,,,5.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,7.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.61,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,7.59,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,7.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.59,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.79,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.33,,,percent of total billed charges,,
POTASSIUM CL INJ 40 MEQ,2500003094,CDM,636,RC,J3480,HCPCS,6332396520,NDC,999,EAPG,,outpatient,facility,20,UN,7.59,7.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLYCOPYRROLATE/FORM 10.7GM INH,2500003109,CDM,637,RC,310460012,NDC,,,,,,inpatient,facility,10.7,UN,1564.63,1564.63,125.17,1564.63,,,,,,,,,,,,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.17,,,percent of total billed charges,,,,,,,,,1564.63,,,percent of total billed charges,,,866.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1427.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,1564.63,,,percent of total billed charges,,,815.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.17,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1098.68,,,percent of total billed charges,,
GLYCOPYRROLATE/FORM 10.7GM INH,2500003109,CDM,637,RC,310460012,NDC,,,,,,outpatient,facility,10.7,UN,1564.63,1564.63,125.17,1564.63,,913.74,,,percent of total billed charges,,,305.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1564.63,,,percent of total billed charges,,,1377.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1377.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1377.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,572.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1408.17,,,percent of total billed charges,,,,,,,,,1564.63,,,percent of total billed charges,,,1059.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1201.64,,,percent of total billed charges,,,,,,,,,,,,,,,844.9,,,percent of total billed charges,,,844.9,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,815.8,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1189.12,,,percent of total billed charges,,,592.68,,,percent of total billed charges,,,810.32,,,percent of total billed charges,,,,,,,,,,,,,,,312.93,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,578.91,,,percent of total billed charges,,,578.91,,,percent of total billed charges,,,1564.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1564.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,125.17,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,1564.63,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,,,,,,,1564.63,,,fee schedule,,,1455.42,,,percent of total billed charges,,,,,,,,,,,,,,,1455.42,,,percent of total billed charges,,,1455.42,,,percent of total billed charges,,,1455.42,,,percent of total billed charges,,,1173.47,,,percent of total billed charges,,,1564.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1564.63,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,782.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1098.68,,,percent of total billed charges,,
GLYCOPYRROLATE/FORM 10.7GM INH,2500003109,CDM,637,RC,310460012,NDC,999,EAPG,,,,outpatient,facility,10.7,UN,1564.63,1564.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REVEFENACIN 175 MCG/3 ML NEB,2500003111,CDM,637,RC,4950280693,NDC,,,,,,inpatient,facility,3,UN,165.17,165.17,13.21,165.17,,,,,,,,,,,,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.65,,,percent of total billed charges,,,,,,,,,165.17,,,percent of total billed charges,,,91.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,165.17,,,percent of total billed charges,,,86.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.21,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.98,,,percent of total billed charges,,
REVEFENACIN 175 MCG/3 ML NEB,2500003111,CDM,637,RC,4950280693,NDC,,,,,,outpatient,facility,3,UN,165.17,165.17,13.21,618.77,,96.46,,,percent of total billed charges,,,32.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,165.17,,,percent of total billed charges,,,145.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,145.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,145.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,60.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,148.65,,,percent of total billed charges,,,,,,,,,165.17,,,percent of total billed charges,,,111.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.85,,,percent of total billed charges,,,,,,,,,,,,,,,89.19,,,percent of total billed charges,,,89.19,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,86.12,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.53,,,percent of total billed charges,,,62.57,,,percent of total billed charges,,,85.54,,,percent of total billed charges,,,,,,,,,,,,,,,33.03,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,61.11,,,percent of total billed charges,,,61.11,,,percent of total billed charges,,,165.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,165.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.21,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,165.17,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,,,,,,,165.17,,,fee schedule,,,153.64,,,percent of total billed charges,,,,,,,,,,,,,,,153.64,,,percent of total billed charges,,,153.64,,,percent of total billed charges,,,153.64,,,percent of total billed charges,,,123.88,,,percent of total billed charges,,,165.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,165.17,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,115.98,,,percent of total billed charges,,
REVEFENACIN 175 MCG/3 ML NEB,2500003111,CDM,637,RC,4950280693,NDC,999,EAPG,,,,outpatient,facility,3,UN,165.17,165.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMINO 8 /D14W 2000 ML,2500003136,CDM,258,RC,338018401,NDC,,,,,,inpatient,facility,2000,UN,270.63,270.63,21.65,270.63,,,,,,,,,,,,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.57,,,percent of total billed charges,,,,,,,,,270.63,,,percent of total billed charges,,,149.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,270.63,,,percent of total billed charges,,,141.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.65,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.04,,,percent of total billed charges,,
AMINO 8 /D14W 2000 ML,2500003136,CDM,258,RC,338018401,NDC,,,,,,outpatient,facility,2000,UN,270.63,270.63,21.65,618.77,,158.05,,,percent of total billed charges,,,52.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,270.63,,,percent of total billed charges,,,238.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,238.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,238.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,99.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,243.57,,,percent of total billed charges,,,,,,,,,270.63,,,percent of total billed charges,,,183.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,141.11,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.68,,,percent of total billed charges,,,102.51,,,percent of total billed charges,,,140.16,,,percent of total billed charges,,,,,,,,,,,,,,,54.13,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,108.25,,,percent of total billed charges,,,108.25,,,percent of total billed charges,,,270.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,270.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.65,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,270.63,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,,,,,,,270.63,,,fee schedule,,,108.25,,,percent of total billed charges,,,,,,,,,,,,,,,108.25,,,percent of total billed charges,,,108.25,,,percent of total billed charges,,,108.25,,,percent of total billed charges,,,202.97,,,percent of total billed charges,,,270.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,270.63,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,190.04,,,percent of total billed charges,,
AMINO 8 /D14W 2000 ML,2500003136,CDM,258,RC,338018401,NDC,999,EAPG,,,,outpatient,facility,2000,UN,270.63,270.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMINO 8 /D14W 2000 ML LYTE,2500003138,CDM,258,RC,338020604,NDC,,,,,,inpatient,facility,2000,UN,399.04,399.04,31.92,399.04,,,,,,,,,,,,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.14,,,percent of total billed charges,,,,,,,,,399.04,,,percent of total billed charges,,,220.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,399.04,,,percent of total billed charges,,,208.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.92,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.21,,,percent of total billed charges,,
AMINO 8 /D14W 2000 ML LYTE,2500003138,CDM,258,RC,338020604,NDC,,,,,,outpatient,facility,2000,UN,399.04,399.04,31.92,618.77,,233.04,,,percent of total billed charges,,,77.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,399.04,,,percent of total billed charges,,,351.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,351.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,351.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,146.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,359.14,,,percent of total billed charges,,,,,,,,,399.04,,,percent of total billed charges,,,270.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,208.06,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.27,,,percent of total billed charges,,,151.16,,,percent of total billed charges,,,206.66,,,percent of total billed charges,,,,,,,,,,,,,,,79.81,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,159.62,,,percent of total billed charges,,,159.62,,,percent of total billed charges,,,399.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,399.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.92,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,399.04,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,,,,,,,399.04,,,fee schedule,,,159.62,,,percent of total billed charges,,,,,,,,,,,,,,,159.62,,,percent of total billed charges,,,159.62,,,percent of total billed charges,,,159.62,,,percent of total billed charges,,,299.28,,,percent of total billed charges,,,399.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,399.04,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,280.21,,,percent of total billed charges,,
AMINO 8 /D14W 2000 ML LYTE,2500003138,CDM,258,RC,338020604,NDC,999,EAPG,,,,outpatient,facility,2000,UN,399.04,399.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SALINE SOLUTION IV 500 ML,2500003150,CDM,636,RC,J7040,HCPCS,264780010,NDC,,,,inpatient,facility,500,ML,11.15,11.15,0.89,11.15,,,,,,,,,,,,,,11.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.04,,,percent of total billed charges,,,,,,,,,11.15,,,percent of total billed charges,,,6.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.15,,,percent of total billed charges,,,,,,,,,,,,,,,11.15,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,11.15,,,percent of total billed charges,,,11.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.83,,,percent of total billed charges,,
SALINE SOLUTION IV 500 ML,2500003150,CDM,636,RC,J7040,HCPCS,264780010,NDC,,,,outpatient,facility,500,ML,11.15,11.15,0.89,618.77,,6.51,,,percent of total billed charges,,,2.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,11.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.04,,,percent of total billed charges,,,,,,,,,11.15,,,percent of total billed charges,,,7.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,11.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,11.15,,,percent of total billed charges,,,11.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.47,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,11.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.89,,,percent of total billed charges,,,11.15,,,percent of total billed charges,,,11.15,,,percent of total billed charges,,,,,,,,,,,,,,,11.15,,,percent of total billed charges,,,11.15,,,percent of total billed charges,,,,,,,,,11.15,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.4,,,fee schedule,,,11.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.15,,,percent of total billed charges,,,11.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.83,,,percent of total billed charges,,
SALINE SOLUTION IV 500 ML,2500003150,CDM,636,RC,J7040,HCPCS,264780010,NDC,496,EAPG,,outpatient,facility,500,ML,11.15,11.15,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W/NORMAL SALINE 500ML,2500003160,CDM,258,RC,J7042,HCPCS,338008903,NDC,,,,inpatient,facility,500,UN,15.61,15.61,1.25,15.61,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.05,,,percent of total billed charges,,,,,,,,,15.61,,,percent of total billed charges,,,8.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,8.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.96,,,percent of total billed charges,,
D5W/NORMAL SALINE 500ML,2500003160,CDM,258,RC,J7042,HCPCS,338008903,NDC,,,,outpatient,facility,500,UN,15.61,15.61,1.2,618.77,,9.12,,,percent of total billed charges,,,3.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,15.61,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,14.05,,,percent of total billed charges,,,,,,,,,15.61,,,percent of total billed charges,,,10.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.14,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.86,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,8.08,,,percent of total billed charges,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,15.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.25,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,,,,,,,15.61,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.2,,,fee schedule,,,15.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,15.61,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.96,,,percent of total billed charges,,
D5W/NORMAL SALINE 500ML,2500003160,CDM,258,RC,J7042,HCPCS,338008903,NDC,999,EAPG,,outpatient,facility,500,UN,15.61,15.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W/NORMAL SALINE 1000ML,2500003162,CDM,258,RC,J7042,HCPCS,264761000,NDC,,,,inpatient,facility,1000,UN,12.51,12.51,1,12.51,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.26,,,percent of total billed charges,,,,,,,,,12.51,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,6.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,
D5W/NORMAL SALINE 1000ML,2500003162,CDM,258,RC,J7042,HCPCS,264761000,NDC,,,,outpatient,facility,1000,UN,12.51,12.51,1,618.77,,7.31,,,percent of total billed charges,,,2.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,12.51,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.26,,,percent of total billed charges,,,,,,,,,12.51,,,percent of total billed charges,,,8.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.52,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.51,,,percent of total billed charges,,,4.74,,,percent of total billed charges,,,6.48,,,percent of total billed charges,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,12.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,,,,,,,12.51,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.2,,,fee schedule,,,12.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,12.51,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.78,,,percent of total billed charges,,
D5W/NORMAL SALINE 1000ML,2500003162,CDM,258,RC,J7042,HCPCS,264761000,NDC,999,EAPG,,outpatient,facility,1000,UN,12.51,12.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZOCAINE/MENT 85 GM SPRAY,2500003167,CDM,637,RC,1686468003,NDC,,,,,,inpatient,facility,85,UN,18.22,18.22,1.46,18.22,,,,,,,,,,,,,,18.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.4,,,percent of total billed charges,,,,,,,,,18.22,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.22,,,percent of total billed charges,,,,,,,,,,,,,,,18.22,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.46,,,percent of total billed charges,,,18.22,,,percent of total billed charges,,,18.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.79,,,percent of total billed charges,,
BENZOCAINE/MENT 85 GM SPRAY,2500003167,CDM,637,RC,1686468003,NDC,,,,,,outpatient,facility,85,UN,18.22,18.22,1.46,618.77,,10.64,,,percent of total billed charges,,,3.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,18.22,,,percent of total billed charges,,,16.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,16.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,16.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,16.4,,,percent of total billed charges,,,,,,,,,18.22,,,percent of total billed charges,,,12.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.99,,,percent of total billed charges,,,,,,,,,,,,,,,9.84,,,percent of total billed charges,,,9.84,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,18.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,18.22,,,percent of total billed charges,,,18.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.85,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.74,,,percent of total billed charges,,,6.74,,,percent of total billed charges,,,18.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.46,,,percent of total billed charges,,,18.22,,,percent of total billed charges,,,18.22,,,percent of total billed charges,,,,,,,,,,,,,,,18.22,,,percent of total billed charges,,,18.22,,,percent of total billed charges,,,,,,,,,18.22,,,fee schedule,,,16.95,,,percent of total billed charges,,,,,,,,,,,,,,,16.95,,,percent of total billed charges,,,16.95,,,percent of total billed charges,,,16.95,,,percent of total billed charges,,,13.66,,,percent of total billed charges,,,18.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,18.22,,,percent of total billed charges,,,18.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.11,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,12.79,,,percent of total billed charges,,
BENZOCAINE/MENT 85 GM SPRAY,2500003167,CDM,637,RC,1686468003,NDC,999,EAPG,,,,outpatient,facility,85,UN,18.22,18.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISAVUCONAZONIUM SUL 186MG CAP,2500003169,CDM,637,RC,J1833,HCPCS,469052002,NDC,,,,inpatient,facility,186,UN,333.2,333.2,26.66,333.2,,,,,,,,,,,,,,333.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.88,,,percent of total billed charges,,,,,,,,,333.2,,,percent of total billed charges,,,184.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,333.2,,,percent of total billed charges,,,,,,,,,,,,,,,333.2,,,percent of total billed charges,,,173.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.66,,,percent of total billed charges,,,333.2,,,percent of total billed charges,,,333.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,333.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.97,,,percent of total billed charges,,
ISAVUCONAZONIUM SUL 186MG CAP,2500003169,CDM,637,RC,J1833,HCPCS,469052002,NDC,,,,outpatient,facility,186,UN,333.2,333.2,0.59,618.77,,194.59,,,percent of total billed charges,,,,,,,,,333.2,,,percent of total billed charges,,,1.39,,,fee schedule,,,1.34,,,fee schedule,,,,,,,,,1.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,333.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,299.88,,,percent of total billed charges,,,,,,,,,333.2,,,percent of total billed charges,,,225.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.9,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,fee schedule,,,1,,,fee schedule,,,,,,,,,618.77,,,per diem,,,333.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.73,,,percent of total billed charges,,,333.2,,,percent of total billed charges,,,333.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.23,,,percent of total billed charges,,,126.22,,,percent of total billed charges,,,172.56,,,percent of total billed charges,,,,,,,,,,,,,,,66.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.9,,,fee schedule,,,0.85,,,fee schedule,,,,,,,,,,,,,,,26.66,,,percent of total billed charges,,,333.2,,,percent of total billed charges,,,333.2,,,percent of total billed charges,,,,,,,,,,,,,,,333.2,,,percent of total billed charges,,,333.2,,,percent of total billed charges,,,,,,,,,333.2,,,fee schedule,,,0.9,,,fee schedule,,,,,,,,,,,,,,,0.8,,,fee schedule,,,1.06,,,fee schedule,,,0.59,,,fee schedule,,,249.9,,,percent of total billed charges,,,333.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,333.2,,,percent of total billed charges,,,333.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,233.97,,,percent of total billed charges,,
ISAVUCONAZONIUM SUL 186MG CAP,2500003169,CDM,637,RC,J1833,HCPCS,469052002,NDC,9456,APC,,outpatient,facility,186,UN,333.2,333.2,0.95,121.95,,,,,,,,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,,,,121.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.99,,,fee schedule,,,,,,,,,,,,,,,0.99,,,fee schedule,,,1.04,,,fee schedule,,,,,,,,,0.99,,,fee schedule,,,0.99,,,fee schedule,,,1.04,,,fee schedule,,,,,,,,,,,,,,,1.44,,,fee schedule,,,,,,,,,,,,,,,0.99,,,fee schedule,,,,,,,,,,,,,,,0.95,,,fee schedule,,,1.06,,,fee schedule,,,1.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,fee schedule,,,0.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.99,,,fee schedule,,,0.99,,,fee schedule,,,,,,,,,,,,,,,0.99,,,fee schedule,,,,,,,,,,,,,,,0.99,,,fee schedule,,,1.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,fee schedule,,,0.99,,,fee schedule,,,1.03,,,fee schedule,,,0.99,,,fee schedule,,,,,,,,,0.99,,,fee schedule,,,,,,,,,0.99,,,fee schedule,,,,,,,,
ISAVUCONAZONIUM SUL 186MG CAP,2500003169,CDM,637,RC,J1833,HCPCS,469052002,NDC,999,EAPG,,outpatient,facility,186,UN,333.2,333.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SALINE SOLUTION IV 250 ML,2500003170,CDM,636,RC,J7050,HCPCS,264780020,NDC,,,,inpatient,facility,250,ML,9.47,9.47,0.76,9.47,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.52,,,percent of total billed charges,,,,,,,,,9.47,,,percent of total billed charges,,,5.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.65,,,percent of total billed charges,,
SALINE SOLUTION IV 250 ML,2500003170,CDM,636,RC,J7050,HCPCS,264780020,NDC,,,,outpatient,facility,250,ML,9.47,9.47,0.69,618.77,,5.53,,,percent of total billed charges,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.47,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.52,,,percent of total billed charges,,,,,,,,,9.47,,,percent of total billed charges,,,6.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,3.59,,,percent of total billed charges,,,4.9,,,percent of total billed charges,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,9.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.76,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,,,,,,,9.47,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.69,,,fee schedule,,,9.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.47,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.65,,,percent of total billed charges,,
SALINE SOLUTION IV 250 ML,2500003170,CDM,636,RC,J7050,HCPCS,264780020,NDC,496,EAPG,,outpatient,facility,250,ML,9.47,9.47,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DAPAGLIFLZN PROPANEDL 10MG TAB,2500003173,CDM,637,RC,310621030,NDC,,,,,,inpatient,facility,10,UN,64.05,64.05,5.12,64.05,,,,,,,,,,,,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.64,,,percent of total billed charges,,,,,,,,,64.05,,,percent of total billed charges,,,35.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,64.05,,,percent of total billed charges,,,33.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.98,,,percent of total billed charges,,
DAPAGLIFLZN PROPANEDL 10MG TAB,2500003173,CDM,637,RC,310621030,NDC,,,,,,outpatient,facility,10,UN,64.05,64.05,5.12,618.77,,37.41,,,percent of total billed charges,,,12.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,64.05,,,percent of total billed charges,,,56.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,56.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,56.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,23.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,57.64,,,percent of total billed charges,,,,,,,,,64.05,,,percent of total billed charges,,,43.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.19,,,percent of total billed charges,,,,,,,,,,,,,,,34.59,,,percent of total billed charges,,,34.59,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.4,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.68,,,percent of total billed charges,,,24.26,,,percent of total billed charges,,,33.17,,,percent of total billed charges,,,,,,,,,,,,,,,12.81,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,23.7,,,percent of total billed charges,,,23.7,,,percent of total billed charges,,,64.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,64.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.12,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,64.05,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,,,,,,,64.05,,,fee schedule,,,59.58,,,percent of total billed charges,,,,,,,,,,,,,,,59.58,,,percent of total billed charges,,,59.58,,,percent of total billed charges,,,59.58,,,percent of total billed charges,,,48.04,,,percent of total billed charges,,,64.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,64.05,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,44.98,,,percent of total billed charges,,
DAPAGLIFLZN PROPANEDL 10MG TAB,2500003173,CDM,637,RC,310621030,NDC,999,EAPG,,,,outpatient,facility,10,UN,64.05,64.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SALINE SOLUTION IV 100 ML,2500003174,CDM,250,RC,J7050,HCPCS,264180032,NDC,,,,inpatient,facility,100,UN,8.98,8.98,0.72,8.98,,,,,,,,,,,,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.08,,,percent of total billed charges,,,,,,,,,8.98,,,percent of total billed charges,,,4.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,8.98,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.31,,,percent of total billed charges,,
SALINE SOLUTION IV 100 ML,2500003174,CDM,250,RC,J7050,HCPCS,264180032,NDC,,,,outpatient,facility,100,UN,8.98,8.98,0.69,618.77,,5.24,,,percent of total billed charges,,,1.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.98,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.08,,,percent of total billed charges,,,,,,,,,8.98,,,percent of total billed charges,,,6.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.82,,,percent of total billed charges,,,3.4,,,percent of total billed charges,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,8.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.72,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,8.98,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,,,,,,,8.98,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.69,,,fee schedule,,,8.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.98,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.31,,,percent of total billed charges,,
SALINE SOLUTION IV 100 ML,2500003174,CDM,250,RC,J7050,HCPCS,264180032,NDC,496,EAPG,,outpatient,facility,100,UN,8.98,8.98,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SALINE SOLUTION 50 ML,2500003176,CDM,250,RC,J7050,HCPCS,264180031,NDC,,,,inpatient,facility,50,UN,8.91,8.91,0.71,8.91,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.02,,,percent of total billed charges,,,,,,,,,8.91,,,percent of total billed charges,,,4.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,
SALINE SOLUTION 50 ML,2500003176,CDM,250,RC,J7050,HCPCS,264180031,NDC,,,,outpatient,facility,50,UN,8.91,8.91,0.69,618.77,,5.2,,,percent of total billed charges,,,1.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.91,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.02,,,percent of total billed charges,,,,,,,,,8.91,,,percent of total billed charges,,,6.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.77,,,percent of total billed charges,,,3.38,,,percent of total billed charges,,,4.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,8.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.71,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,8.91,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.69,,,fee schedule,,,8.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.91,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.26,,,percent of total billed charges,,
SALINE SOLUTION 50 ML,2500003176,CDM,250,RC,J7050,HCPCS,264180031,NDC,496,EAPG,,outpatient,facility,50,UN,8.91,8.91,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W 500 ML,2500003190,CDM,258,RC,J7060,HCPCS,6521946020,NDC,,,,inpatient,facility,500,UN,12.28,12.28,0.98,12.28,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.05,,,percent of total billed charges,,,,,,,,,12.28,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,6.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.62,,,percent of total billed charges,,
D5W 500 ML,2500003190,CDM,258,RC,J7060,HCPCS,6521946020,NDC,,,,outpatient,facility,500,UN,12.28,12.28,0.98,618.77,,7.17,,,percent of total billed charges,,,2.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,12.28,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.05,,,percent of total billed charges,,,,,,,,,12.28,,,percent of total billed charges,,,8.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.4,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.33,,,percent of total billed charges,,,4.65,,,percent of total billed charges,,,6.36,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,12.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.98,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,,,,,,,12.28,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.74,,,fee schedule,,,12.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,12.28,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.62,,,percent of total billed charges,,
D5W 500 ML,2500003190,CDM,258,RC,J7060,HCPCS,6521946020,NDC,496,EAPG,,outpatient,facility,500,UN,12.28,12.28,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W 250 ML,2500003191,CDM,636,RC,J7060,HCPCS,264751020,NDC,,,,inpatient,facility,250,UN,11.25,11.25,0.9,11.25,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.13,,,percent of total billed charges,,,,,,,,,11.25,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.9,,,percent of total billed charges,,
D5W 250 ML,2500003191,CDM,636,RC,J7060,HCPCS,264751020,NDC,,,,outpatient,facility,250,UN,11.25,11.25,0.9,618.77,,6.57,,,percent of total billed charges,,,2.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.13,,,percent of total billed charges,,,,,,,,,11.25,,,percent of total billed charges,,,7.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.55,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,5.83,,,percent of total billed charges,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,11.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.9,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,,,,,,,11.25,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.74,,,fee schedule,,,11.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.25,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.9,,,percent of total billed charges,,
D5W 250 ML,2500003191,CDM,636,RC,J7060,HCPCS,264751020,NDC,496,EAPG,,outpatient,facility,250,UN,11.25,11.25,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W 100 ML,2500003194,CDM,258,RC,J7060,HCPCS,264151032,NDC,,,,inpatient,facility,100,UN,8.15,8.15,0.65,8.15,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.34,,,percent of total billed charges,,,,,,,,,8.15,,,percent of total billed charges,,,4.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,4.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.72,,,percent of total billed charges,,
D5W 100 ML,2500003194,CDM,258,RC,J7060,HCPCS,264151032,NDC,,,,outpatient,facility,100,UN,8.15,8.15,0.65,618.77,,4.76,,,percent of total billed charges,,,1.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.34,,,percent of total billed charges,,,,,,,,,8.15,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.25,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,8.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.65,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,8.15,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.74,,,fee schedule,,,8.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.08,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.72,,,percent of total billed charges,,
D5W 100 ML,2500003194,CDM,258,RC,J7060,HCPCS,264151032,NDC,496,EAPG,,outpatient,facility,100,UN,8.15,8.15,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W 50ML,2500003196,CDM,636,RC,J7060,HCPCS,264151031,NDC,,,,inpatient,facility,50,UN,8.15,8.15,0.65,8.15,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.34,,,percent of total billed charges,,,,,,,,,8.15,,,percent of total billed charges,,,4.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,4.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.72,,,percent of total billed charges,,
D5W 50ML,2500003196,CDM,636,RC,J7060,HCPCS,264151031,NDC,,,,outpatient,facility,50,UN,8.15,8.15,0.65,618.77,,4.76,,,percent of total billed charges,,,1.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.34,,,percent of total billed charges,,,,,,,,,8.15,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.25,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,8.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.65,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,8.15,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.74,,,fee schedule,,,8.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.08,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.72,,,percent of total billed charges,,
D5W 50ML,2500003196,CDM,636,RC,J7060,HCPCS,264151031,NDC,496,EAPG,,outpatient,facility,50,UN,8.15,8.15,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W INFUSION 1000 ML,2500003200,CDM,258,RC,J7060,HCPCS,264751000,NDC,,,,inpatient,facility,1000,UN,13.27,13.27,1.06,13.27,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.94,,,percent of total billed charges,,,,,,,,,13.27,,,percent of total billed charges,,,7.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,6.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.32,,,percent of total billed charges,,
D5W INFUSION 1000 ML,2500003200,CDM,258,RC,J7060,HCPCS,264751000,NDC,,,,outpatient,facility,1000,UN,13.27,13.27,1.06,618.77,,7.75,,,percent of total billed charges,,,2.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.27,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.94,,,percent of total billed charges,,,,,,,,,13.27,,,percent of total billed charges,,,8.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.92,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.09,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,6.87,,,percent of total billed charges,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,13.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.06,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,13.27,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.74,,,fee schedule,,,13.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.32,,,percent of total billed charges,,
D5W INFUSION 1000 ML,2500003200,CDM,258,RC,J7060,HCPCS,264751000,NDC,496,EAPG,,outpatient,facility,1000,UN,13.27,13.27,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RINGERS LACTATE INFUS 500 ML,2500003231,CDM,636,RC,J7120,HCPCS,338011703,NDC,,,,inpatient,facility,500,ML,15.21,15.21,1.22,15.21,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,15.21,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,7.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.68,,,percent of total billed charges,,
RINGERS LACTATE INFUS 500 ML,2500003231,CDM,636,RC,J7120,HCPCS,338011703,NDC,,,,outpatient,facility,500,ML,15.21,15.21,1.22,618.77,,8.88,,,percent of total billed charges,,,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,15.21,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.69,,,percent of total billed charges,,,,,,,,,15.21,,,percent of total billed charges,,,10.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.93,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.56,,,percent of total billed charges,,,5.76,,,percent of total billed charges,,,7.88,,,percent of total billed charges,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,15.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.22,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,,,,,,,15.21,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.55,,,fee schedule,,,15.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,15.21,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.68,,,percent of total billed charges,,
RINGERS LACTATE INFUS 500 ML,2500003231,CDM,636,RC,J7120,HCPCS,338011703,NDC,496,EAPG,,outpatient,facility,500,ML,15.21,15.21,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OLOPATADNE 0.2  OPH SOLN 2.5ML,2500003292,CDM,637,RC,6233250203,NDC,,,,,,inpatient,facility,2.5,UN,591.99,591.99,47.36,591.99,,,,,,,,,,,,,,591.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,532.79,,,percent of total billed charges,,,,,,,,,591.99,,,percent of total billed charges,,,327.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,540.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,591.99,,,percent of total billed charges,,,,,,,,,,,,,,,591.99,,,percent of total billed charges,,,308.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.36,,,percent of total billed charges,,,591.99,,,percent of total billed charges,,,591.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,591.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,415.7,,,percent of total billed charges,,
OLOPATADNE 0.2  OPH SOLN 2.5ML,2500003292,CDM,637,RC,6233250203,NDC,,,,,,outpatient,facility,2.5,UN,591.99,591.99,47.36,618.77,,345.72,,,percent of total billed charges,,,115.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,591.99,,,percent of total billed charges,,,521.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,521.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,521.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,591.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,216.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,532.79,,,percent of total billed charges,,,,,,,,,591.99,,,percent of total billed charges,,,400.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,454.65,,,percent of total billed charges,,,,,,,,,,,,,,,319.67,,,percent of total billed charges,,,319.67,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,591.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,308.66,,,percent of total billed charges,,,591.99,,,percent of total billed charges,,,591.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,449.91,,,percent of total billed charges,,,224.25,,,percent of total billed charges,,,306.59,,,percent of total billed charges,,,,,,,,,,,,,,,118.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,219.04,,,percent of total billed charges,,,219.04,,,percent of total billed charges,,,591.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,591.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,47.36,,,percent of total billed charges,,,591.99,,,percent of total billed charges,,,591.99,,,percent of total billed charges,,,,,,,,,,,,,,,591.99,,,percent of total billed charges,,,591.99,,,percent of total billed charges,,,,,,,,,591.99,,,fee schedule,,,550.67,,,percent of total billed charges,,,,,,,,,,,,,,,550.67,,,percent of total billed charges,,,550.67,,,percent of total billed charges,,,550.67,,,percent of total billed charges,,,443.99,,,percent of total billed charges,,,591.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,591.99,,,percent of total billed charges,,,591.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,415.7,,,percent of total billed charges,,
OLOPATADNE 0.2  OPH SOLN 2.5ML,2500003292,CDM,637,RC,6233250203,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,591.99,591.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAMINOPHEN 80 MG SUPP,2500003304,CDM,637,RC,5167221142,NDC,,,,,,inpatient,facility,80,UN,2.64,2.64,0.21,2.64,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,
ACETAMINOPHEN 80 MG SUPP,2500003304,CDM,637,RC,5167221142,NDC,,,,,,outpatient,facility,80,UN,2.64,2.64,0.21,618.77,,1.54,,,percent of total billed charges,,,0.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.64,,,percent of total billed charges,,,2.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.38,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.98,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,2.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,2.64,,,fee schedule,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,2.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.85,,,percent of total billed charges,,
ACETAMINOPHEN 80 MG SUPP,2500003304,CDM,637,RC,5167221142,NDC,999,EAPG,,,,outpatient,facility,80,UN,2.64,2.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COVID-19 30MCG/ 0.3ML PFIZFER,2500003306,CDM,636,RC,91300,CPT,,,,,,inpatient,facility,,,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
COVID-19 30MCG/ 0.3ML PFIZFER,2500003306,CDM,636,RC,91300,CPT,,,,,,outpatient,facility,,,0.01,0.01,0.01,618.77,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.01,,,percent of total billed charges,,
COVID-19 30MCG/ 0.3ML PFIZFER,2500003306,CDM,636,RC,91300,CPT,999,EAPG,,,,outpatient,facility,,,0.01,0.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COVID-19 100MCG/0.5ML MODERNA,2500003307,CDM,636,RC,91301,CPT,,,,,,inpatient,facility,,,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
COVID-19 100MCG/0.5ML MODERNA,2500003307,CDM,636,RC,91301,CPT,,,,,,outpatient,facility,,,0.01,0.01,0.01,618.77,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.01,,,percent of total billed charges,,
COVID-19 100MCG/0.5ML MODERNA,2500003307,CDM,636,RC,91301,CPT,999,EAPG,,,,outpatient,facility,,,0.01,0.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AZATHIOPRINE 50 MG TAB,2500003322,CDM,637,RC,J7500,HCPCS,6838200301,NDC,,,,inpatient,facility,50,UN,6.96,6.96,0.56,6.96,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,,,,,,,6.96,,,percent of total billed charges,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,
AZATHIOPRINE 50 MG TAB,2500003322,CDM,637,RC,J7500,HCPCS,6838200301,NDC,,,,outpatient,facility,50,UN,6.96,6.96,0.56,618.77,,4.06,,,percent of total billed charges,,,1.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.96,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.26,,,percent of total billed charges,,,,,,,,,6.96,,,percent of total billed charges,,,4.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.29,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,6.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,6.96,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.9,,,fee schedule,,,6.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.89,,,percent of total billed charges,,
AZATHIOPRINE 50 MG TAB,2500003322,CDM,637,RC,J7500,HCPCS,6838200301,NDC,496,EAPG,,outpatient,facility,50,UN,6.96,6.96,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACOSAMIDE 10 MG/ML 200 ML,2500003323,CDM,637,RC,131541072,NDC,,,,,,inpatient,facility,200,UN,1263.8,1263.8,101.1,1263.8,,,,,,,,,,,,,,1263.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1137.42,,,percent of total billed charges,,,,,,,,,1263.8,,,percent of total billed charges,,,699.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1153.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1263.8,,,percent of total billed charges,,,,,,,,,,,,,,,1263.8,,,percent of total billed charges,,,658.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.1,,,percent of total billed charges,,,1263.8,,,percent of total billed charges,,,1263.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1263.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,887.44,,,percent of total billed charges,,
LACOSAMIDE 10 MG/ML 200 ML,2500003323,CDM,637,RC,131541072,NDC,,,,,,outpatient,facility,200,UN,1263.8,1263.8,101.1,1263.8,,738.06,,,percent of total billed charges,,,246.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1263.8,,,percent of total billed charges,,,1112.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1112.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1112.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1263.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,462.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1137.42,,,percent of total billed charges,,,,,,,,,1263.8,,,percent of total billed charges,,,855.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,970.6,,,percent of total billed charges,,,,,,,,,,,,,,,682.45,,,percent of total billed charges,,,682.45,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1263.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,658.95,,,percent of total billed charges,,,1263.8,,,percent of total billed charges,,,1263.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,960.49,,,percent of total billed charges,,,478.73,,,percent of total billed charges,,,654.52,,,percent of total billed charges,,,,,,,,,,,,,,,252.76,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,467.61,,,percent of total billed charges,,,467.61,,,percent of total billed charges,,,1263.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1263.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,101.1,,,percent of total billed charges,,,1263.8,,,percent of total billed charges,,,1263.8,,,percent of total billed charges,,,,,,,,,,,,,,,1263.8,,,percent of total billed charges,,,1263.8,,,percent of total billed charges,,,,,,,,,1263.8,,,fee schedule,,,1175.59,,,percent of total billed charges,,,,,,,,,,,,,,,1175.59,,,percent of total billed charges,,,1175.59,,,percent of total billed charges,,,1175.59,,,percent of total billed charges,,,947.85,,,percent of total billed charges,,,1263.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1263.8,,,percent of total billed charges,,,1263.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,887.44,,,percent of total billed charges,,
LACOSAMIDE 10 MG/ML 200 ML,2500003323,CDM,637,RC,131541072,NDC,999,EAPG,,,,outpatient,facility,200,UN,1263.8,1263.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACOSAMIDE 10 MG/ML 20 ML,2500003327,CDM,637,RC,131541072,NDC,,,,,,inpatient,facility,20,UN,126.39,126.39,10.11,126.39,,,,,,,,,,,,,,126.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.75,,,percent of total billed charges,,,,,,,,,126.39,,,percent of total billed charges,,,69.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.39,,,percent of total billed charges,,,,,,,,,,,,,,,126.39,,,percent of total billed charges,,,65.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.11,,,percent of total billed charges,,,126.39,,,percent of total billed charges,,,126.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.75,,,percent of total billed charges,,
LACOSAMIDE 10 MG/ML 20 ML,2500003327,CDM,637,RC,131541072,NDC,,,,,,outpatient,facility,20,UN,126.39,126.39,10.11,618.77,,73.81,,,percent of total billed charges,,,24.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,126.39,,,percent of total billed charges,,,111.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,111.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,111.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,126.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,46.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,113.75,,,percent of total billed charges,,,,,,,,,126.39,,,percent of total billed charges,,,85.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.07,,,percent of total billed charges,,,,,,,,,,,,,,,68.25,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,126.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.9,,,percent of total billed charges,,,126.39,,,percent of total billed charges,,,126.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.06,,,percent of total billed charges,,,47.88,,,percent of total billed charges,,,65.46,,,percent of total billed charges,,,,,,,,,,,,,,,25.28,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,46.76,,,percent of total billed charges,,,46.76,,,percent of total billed charges,,,126.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,126.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.11,,,percent of total billed charges,,,126.39,,,percent of total billed charges,,,126.39,,,percent of total billed charges,,,,,,,,,,,,,,,126.39,,,percent of total billed charges,,,126.39,,,percent of total billed charges,,,,,,,,,126.39,,,fee schedule,,,117.57,,,percent of total billed charges,,,,,,,,,,,,,,,117.57,,,percent of total billed charges,,,117.57,,,percent of total billed charges,,,117.57,,,percent of total billed charges,,,94.79,,,percent of total billed charges,,,126.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,126.39,,,percent of total billed charges,,,126.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,88.75,,,percent of total billed charges,,
LACOSAMIDE 10 MG/ML 20 ML,2500003327,CDM,637,RC,131541072,NDC,999,EAPG,,,,outpatient,facility,20,UN,126.39,126.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACOSAMIDE 10 MG/ML 10 ML,2500003328,CDM,637,RC,131541072,NDC,,,,,,inpatient,facility,10,UN,63.16,63.16,5.05,63.16,,,,,,,,,,,,,,63.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.84,,,percent of total billed charges,,,,,,,,,63.16,,,percent of total billed charges,,,34.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.16,,,percent of total billed charges,,,,,,,,,,,,,,,63.16,,,percent of total billed charges,,,32.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.05,,,percent of total billed charges,,,63.16,,,percent of total billed charges,,,63.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.35,,,percent of total billed charges,,
LACOSAMIDE 10 MG/ML 10 ML,2500003328,CDM,637,RC,131541072,NDC,,,,,,outpatient,facility,10,UN,63.16,63.16,5.05,618.77,,36.89,,,percent of total billed charges,,,12.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,63.16,,,percent of total billed charges,,,55.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,55.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,55.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,63.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,23.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,56.84,,,percent of total billed charges,,,,,,,,,63.16,,,percent of total billed charges,,,42.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.51,,,percent of total billed charges,,,,,,,,,,,,,,,34.11,,,percent of total billed charges,,,34.11,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,63.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.93,,,percent of total billed charges,,,63.16,,,percent of total billed charges,,,63.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,32.71,,,percent of total billed charges,,,,,,,,,,,,,,,12.63,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,23.37,,,percent of total billed charges,,,23.37,,,percent of total billed charges,,,63.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,63.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.05,,,percent of total billed charges,,,63.16,,,percent of total billed charges,,,63.16,,,percent of total billed charges,,,,,,,,,,,,,,,63.16,,,percent of total billed charges,,,63.16,,,percent of total billed charges,,,,,,,,,63.16,,,fee schedule,,,58.75,,,percent of total billed charges,,,,,,,,,,,,,,,58.75,,,percent of total billed charges,,,58.75,,,percent of total billed charges,,,58.75,,,percent of total billed charges,,,47.37,,,percent of total billed charges,,,63.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,63.16,,,percent of total billed charges,,,63.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,44.35,,,percent of total billed charges,,
LACOSAMIDE 10 MG/ML 10 ML,2500003328,CDM,637,RC,131541072,NDC,999,EAPG,,,,outpatient,facility,10,UN,63.16,63.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRANEXAMIC ACID 1000 MG/10 ML,2500003334,CDM,250,RC,13111415,NDC,,,,,,inpatient,facility,10,UN,67.32,67.32,5.39,67.32,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.59,,,percent of total billed charges,,,,,,,,,67.32,,,percent of total billed charges,,,37.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.39,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.27,,,percent of total billed charges,,
TRANEXAMIC ACID 1000 MG/10 ML,2500003334,CDM,250,RC,13111415,NDC,,,,,,outpatient,facility,10,UN,67.32,67.32,5.39,618.77,,39.31,,,percent of total billed charges,,,13.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,67.32,,,percent of total billed charges,,,59.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,59.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,59.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,24.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,60.59,,,percent of total billed charges,,,,,,,,,67.32,,,percent of total billed charges,,,45.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.16,,,percent of total billed charges,,,25.5,,,percent of total billed charges,,,34.87,,,percent of total billed charges,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,26.93,,,percent of total billed charges,,,26.93,,,percent of total billed charges,,,67.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,67.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.39,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,,,,,,,67.32,,,fee schedule,,,26.93,,,percent of total billed charges,,,,,,,,,,,,,,,26.93,,,percent of total billed charges,,,26.93,,,percent of total billed charges,,,26.93,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,67.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,67.32,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,47.27,,,percent of total billed charges,,
TRANEXAMIC ACID 1000 MG/10 ML,2500003334,CDM,250,RC,13111415,NDC,999,EAPG,,,,outpatient,facility,10,UN,67.32,67.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE/MELOXICAM 14ML INJ,2500003337,CDM,250,RC,4742630102,NDC,,,,,,inpatient,facility,14,UN,973.2,973.2,77.86,973.2,,,,,,,,,,,,,,973.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,875.88,,,percent of total billed charges,,,,,,,,,973.2,,,percent of total billed charges,,,538.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,887.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,973.2,,,percent of total billed charges,,,,,,,,,,,,,,,973.2,,,percent of total billed charges,,,507.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.86,,,percent of total billed charges,,,973.2,,,percent of total billed charges,,,973.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,973.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,683.38,,,percent of total billed charges,,
BUPIVACAINE/MELOXICAM 14ML INJ,2500003337,CDM,250,RC,4742630102,NDC,,,,,,outpatient,facility,14,UN,973.2,973.2,77.86,973.2,,568.35,,,percent of total billed charges,,,189.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,973.2,,,percent of total billed charges,,,856.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,856.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,856.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,973.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,356.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,875.88,,,percent of total billed charges,,,,,,,,,973.2,,,percent of total billed charges,,,659.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,747.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,973.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,507.43,,,percent of total billed charges,,,973.2,,,percent of total billed charges,,,973.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.63,,,percent of total billed charges,,,368.65,,,percent of total billed charges,,,504.02,,,percent of total billed charges,,,,,,,,,,,,,,,194.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,389.28,,,percent of total billed charges,,,389.28,,,percent of total billed charges,,,973.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,973.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,77.86,,,percent of total billed charges,,,973.2,,,percent of total billed charges,,,973.2,,,percent of total billed charges,,,,,,,,,,,,,,,973.2,,,percent of total billed charges,,,973.2,,,percent of total billed charges,,,,,,,,,973.2,,,fee schedule,,,389.28,,,percent of total billed charges,,,,,,,,,,,,,,,389.28,,,percent of total billed charges,,,389.28,,,percent of total billed charges,,,389.28,,,percent of total billed charges,,,729.9,,,percent of total billed charges,,,973.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,973.2,,,percent of total billed charges,,,973.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,486.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,683.38,,,percent of total billed charges,,
BUPIVACAINE/MELOXICAM 14ML INJ,2500003337,CDM,250,RC,4742630102,NDC,999,EAPG,,,,outpatient,facility,14,UN,973.2,973.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CYCLOSPORINE ORAL 25 MG,2500003344,CDM,637,RC,J7515,HCPCS,5186245847,NDC,,,,inpatient,facility,25,UN,4.55,4.55,0.36,4.55,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,4.55,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,
CYCLOSPORINE ORAL 25 MG,2500003344,CDM,637,RC,J7515,HCPCS,5186245847,NDC,,,,outpatient,facility,25,UN,4.55,4.55,0.36,618.77,,2.66,,,percent of total billed charges,,,0.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.09,,,percent of total billed charges,,,,,,,,,4.55,,,percent of total billed charges,,,3.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,4.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.36,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,,,,,,,4.55,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.83,,,fee schedule,,,4.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.55,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.2,,,percent of total billed charges,,
CYCLOSPORINE ORAL 25 MG,2500003344,CDM,637,RC,J7515,HCPCS,5186245847,NDC,496,EAPG,,outpatient,facility,25,UN,4.55,4.55,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACTULOSE 300ML/700ML NS ENEMA,2500003366,CDM,637,RC,121115400,NDC,,,,,,inpatient,facility,1000,UN,199.65,199.65,15.97,199.65,,,,,,,,,,,,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.69,,,percent of total billed charges,,,,,,,,,199.65,,,percent of total billed charges,,,110.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,199.65,,,percent of total billed charges,,,104.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.97,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.19,,,percent of total billed charges,,
LACTULOSE 300ML/700ML NS ENEMA,2500003366,CDM,637,RC,121115400,NDC,,,,,,outpatient,facility,1000,UN,199.65,199.65,15.97,618.77,,116.6,,,percent of total billed charges,,,38.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,199.65,,,percent of total billed charges,,,175.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,175.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,175.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,73.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,179.69,,,percent of total billed charges,,,,,,,,,199.65,,,percent of total billed charges,,,135.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.33,,,percent of total billed charges,,,,,,,,,,,,,,,107.81,,,percent of total billed charges,,,107.81,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,104.1,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.73,,,percent of total billed charges,,,75.63,,,percent of total billed charges,,,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,39.93,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,73.87,,,percent of total billed charges,,,73.87,,,percent of total billed charges,,,199.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,199.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.97,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,199.65,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,,,,,,,199.65,,,fee schedule,,,185.71,,,percent of total billed charges,,,,,,,,,,,,,,,185.71,,,percent of total billed charges,,,185.71,,,percent of total billed charges,,,185.71,,,percent of total billed charges,,,149.74,,,percent of total billed charges,,,199.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,199.65,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,140.19,,,percent of total billed charges,,
LACTULOSE 300ML/700ML NS ENEMA,2500003366,CDM,637,RC,121115400,NDC,999,EAPG,,,,outpatient,facility,1000,UN,199.65,199.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NORTHNDRNE-ETHIN ESTRADIOL TAB,2500003384,CDM,637,RC,555900942,NDC,,,,,,inpatient,facility,1,UN,4.12,4.12,0.33,4.12,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.71,,,percent of total billed charges,,,,,,,,,4.12,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,
NORTHNDRNE-ETHIN ESTRADIOL TAB,2500003384,CDM,637,RC,555900942,NDC,,,,,,outpatient,facility,1,UN,4.12,4.12,0.33,618.77,,2.41,,,percent of total billed charges,,,0.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.12,,,percent of total billed charges,,,3.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.71,,,percent of total billed charges,,,,,,,,,4.12,,,percent of total billed charges,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,4.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.33,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,4.12,,,fee schedule,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.89,,,percent of total billed charges,,
NORTHNDRNE-ETHIN ESTRADIOL TAB,2500003384,CDM,637,RC,555900942,NDC,999,EAPG,,,,outpatient,facility,1,UN,4.12,4.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 4  PATCH,2500003385,CDM,637,RC,536120215,NDC,,,,,,inpatient,facility,1,UN,4.12,4.12,0.33,4.12,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.71,,,percent of total billed charges,,,,,,,,,4.12,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,
LIDOCAINE 4  PATCH,2500003385,CDM,637,RC,536120215,NDC,,,,,,outpatient,facility,1,UN,4.12,4.12,0.33,618.77,,2.41,,,percent of total billed charges,,,0.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.12,,,percent of total billed charges,,,3.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.71,,,percent of total billed charges,,,,,,,,,4.12,,,percent of total billed charges,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,4.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.33,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,4.12,,,fee schedule,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.89,,,percent of total billed charges,,
LIDOCAINE 4  PATCH,2500003385,CDM,637,RC,536120215,NDC,999,EAPG,,,,outpatient,facility,1,UN,4.12,4.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREDNISOLONE 15MG,2500003412,CDM,636,RC,J7510,HCPCS,5038304224,NDC,,,,inpatient,facility,5,UN,7.95,7.95,0.64,7.95,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,7.95,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.58,,,percent of total billed charges,,
PREDNISOLONE 15MG,2500003412,CDM,636,RC,J7510,HCPCS,5038304224,NDC,,,,outpatient,facility,5,UN,7.95,7.95,0.25,618.77,,4.64,,,percent of total billed charges,,,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.16,,,percent of total billed charges,,,,,,,,,7.95,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.15,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.04,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,7.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.64,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,7.95,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.25,,,fee schedule,,,7.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.58,,,percent of total billed charges,,
PREDNISOLONE 15MG,2500003412,CDM,636,RC,J7510,HCPCS,5038304224,NDC,496,EAPG,,outpatient,facility,5,UN,7.95,7.95,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUTEROL SULF INH SOL.083 3ML,2500003440,CDM,637,RC,J7613,HCPCS,487950101,NDC,,,,inpatient,facility,3,UN,2.64,2.64,0.21,2.64,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,
ALBUTEROL SULF INH SOL.083 3ML,2500003440,CDM,637,RC,J7613,HCPCS,487950101,NDC,,,,outpatient,facility,3,UN,2.64,2.64,0.03,618.77,,1.54,,,percent of total billed charges,,,0.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.64,,,percent of total billed charges,,,0.06,,,fee schedule,,,0.06,,,fee schedule,,,,,,,,,0.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.38,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,fee schedule,,,0.04,,,fee schedule,,,,,,,,,618.77,,,per diem,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.09,,,fee schedule,,,0.04,,,fee schedule,,,2.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,0.07,,,fee schedule,,,0.04,,,fee schedule,,,,,,,,,,,,,,,0.04,,,fee schedule,,,0.05,,,fee schedule,,,0.03,,,fee schedule,,,0.04,,,fee schedule,,,2.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.85,,,percent of total billed charges,,
ALBUTEROL SULF INH SOL.083 3ML,2500003440,CDM,637,RC,J7613,HCPCS,487950101,NDC,999,EAPG,,outpatient,facility,3,UN,2.64,2.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MOLNUPIRAVIR 200 MG CAP,2500003450,CDM,637,RC,6505506,NDC,,,,,,inpatient,facility,200,UN,72.6,72.6,5.81,72.6,,,,,,,,,,,,,,72.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.34,,,percent of total billed charges,,,,,,,,,72.6,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.6,,,percent of total billed charges,,,,,,,,,,,,,,,72.6,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,72.6,,,percent of total billed charges,,,72.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.98,,,percent of total billed charges,,
MOLNUPIRAVIR 200 MG CAP,2500003450,CDM,637,RC,6505506,NDC,,,,,,outpatient,facility,200,UN,72.6,72.6,5.81,618.77,,42.4,,,percent of total billed charges,,,14.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,72.6,,,percent of total billed charges,,,63.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,63.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,63.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,72.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,26.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,65.34,,,percent of total billed charges,,,,,,,,,72.6,,,percent of total billed charges,,,49.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.76,,,percent of total billed charges,,,,,,,,,,,,,,,39.2,,,percent of total billed charges,,,39.2,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,72.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,72.6,,,percent of total billed charges,,,72.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.18,,,percent of total billed charges,,,27.5,,,percent of total billed charges,,,37.6,,,percent of total billed charges,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,26.86,,,percent of total billed charges,,,26.86,,,percent of total billed charges,,,72.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,72.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.81,,,percent of total billed charges,,,72.6,,,percent of total billed charges,,,72.6,,,percent of total billed charges,,,,,,,,,,,,,,,72.6,,,percent of total billed charges,,,72.6,,,percent of total billed charges,,,,,,,,,72.6,,,fee schedule,,,67.53,,,percent of total billed charges,,,,,,,,,,,,,,,67.53,,,percent of total billed charges,,,67.53,,,percent of total billed charges,,,67.53,,,percent of total billed charges,,,54.45,,,percent of total billed charges,,,72.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,72.6,,,percent of total billed charges,,,72.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,50.98,,,percent of total billed charges,,
MOLNUPIRAVIR 200 MG CAP,2500003450,CDM,637,RC,6505506,NDC,999,EAPG,,,,outpatient,facility,200,UN,72.6,72.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIRMATRLVIR/RITNVIR 150-100 DP,2500003452,CDM,637,RC,69532130,NDC,,,,,,inpatient,facility,1,UN,212.42,212.42,16.99,212.42,,,,,,,,,,,,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.18,,,percent of total billed charges,,,,,,,,,212.42,,,percent of total billed charges,,,117.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,212.42,,,percent of total billed charges,,,110.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.99,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.16,,,percent of total billed charges,,
NIRMATRLVIR/RITNVIR 150-100 DP,2500003452,CDM,637,RC,69532130,NDC,,,,,,outpatient,facility,1,UN,212.42,212.42,16.99,618.77,,124.05,,,percent of total billed charges,,,41.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,212.42,,,percent of total billed charges,,,187.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,187.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,187.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,77.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,191.18,,,percent of total billed charges,,,,,,,,,212.42,,,percent of total billed charges,,,143.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.14,,,percent of total billed charges,,,,,,,,,,,,,,,114.71,,,percent of total billed charges,,,114.71,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,110.76,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.44,,,percent of total billed charges,,,80.46,,,percent of total billed charges,,,110.01,,,percent of total billed charges,,,,,,,,,,,,,,,42.48,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,78.6,,,percent of total billed charges,,,78.6,,,percent of total billed charges,,,212.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,212.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.99,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,212.42,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,,,,,,,212.42,,,fee schedule,,,197.59,,,percent of total billed charges,,,,,,,,,,,,,,,197.59,,,percent of total billed charges,,,197.59,,,percent of total billed charges,,,197.59,,,percent of total billed charges,,,159.31,,,percent of total billed charges,,,212.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,212.42,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,149.16,,,percent of total billed charges,,
NIRMATRLVIR/RITNVIR 150-100 DP,2500003452,CDM,637,RC,69532130,NDC,999,EAPG,,,,outpatient,facility,1,UN,212.42,212.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCIUM CITRATE/VIT D3 TAB,2500003479,CDM,637,RC,4098527492,NDC,,,,,,inpatient,facility,1,UN,0.17,0.17,0.01,0.17,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,,,,,,,0.17,,,percent of total billed charges,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,
CALCIUM CITRATE/VIT D3 TAB,2500003479,CDM,637,RC,4098527492,NDC,,,,,,outpatient,facility,1,UN,0.17,0.17,0.01,618.77,,0.1,,,percent of total billed charges,,,0.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,0.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.15,,,percent of total billed charges,,,,,,,,,0.17,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,0.09,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,0.06,,,percent of total billed charges,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.06,,,percent of total billed charges,,,0.06,,,percent of total billed charges,,,0.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,0.17,,,fee schedule,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,0.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.17,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.12,,,percent of total billed charges,,
CALCIUM CITRATE/VIT D3 TAB,2500003479,CDM,637,RC,4098527492,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.17,0.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRN 10000MGC/10ML SYR,2500003483,CDM,637,RC,J2371,HCPCS,6937495710,NDC,,,,inpatient,facility,10,UN,19.8,19.8,1.58,19.8,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,19.8,,,percent of total billed charges,,,10.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.9,,,percent of total billed charges,,
PHENYLEPHRN 10000MGC/10ML SYR,2500003483,CDM,637,RC,J2371,HCPCS,6937495710,NDC,,,,outpatient,facility,10,UN,19.8,19.8,1.58,618.77,,11.56,,,percent of total billed charges,,,3.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,19.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,17.82,,,percent of total billed charges,,,,,,,,,19.8,,,percent of total billed charges,,,13.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.32,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.05,,,percent of total billed charges,,,7.5,,,percent of total billed charges,,,10.25,,,percent of total billed charges,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,19.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.58,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,19.8,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,14.85,,,percent of total billed charges,,,19.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,13.9,,,percent of total billed charges,,
PHENYLEPHRN 10000MGC/10ML SYR,2500003483,CDM,637,RC,J2371,HCPCS,6937495710,NDC,999,EAPG,,outpatient,facility,10,UN,19.8,19.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CIPROFLXACIN 0.3  OPH 20DRP/ML,2500003486,CDM,637,RC,6931530805,NDC,,,,,,inpatient,facility,1,UN,9.24,9.24,0.74,9.24,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.32,,,percent of total billed charges,,,,,,,,,9.24,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.49,,,percent of total billed charges,,
CIPROFLXACIN 0.3  OPH 20DRP/ML,2500003486,CDM,637,RC,6931530805,NDC,,,,,,outpatient,facility,1,UN,9.24,9.24,0.74,618.77,,5.4,,,percent of total billed charges,,,1.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.24,,,percent of total billed charges,,,8.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,8.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,8.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.32,,,percent of total billed charges,,,,,,,,,9.24,,,percent of total billed charges,,,6.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.1,,,percent of total billed charges,,,,,,,,,,,,,,,4.99,,,percent of total billed charges,,,4.99,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.82,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.02,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.42,,,percent of total billed charges,,,3.42,,,percent of total billed charges,,,9.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.74,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,,,,,,,9.24,,,fee schedule,,,8.6,,,percent of total billed charges,,,,,,,,,,,,,,,8.6,,,percent of total billed charges,,,8.6,,,percent of total billed charges,,,8.6,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,9.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.24,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.49,,,percent of total billed charges,,
CIPROFLXACIN 0.3  OPH 20DRP/ML,2500003486,CDM,637,RC,6931530805,NDC,999,EAPG,,,,outpatient,facility,1,UN,9.24,9.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IPRATROPIUM .02  NEB 2.5 ML,2500003490,CDM,637,RC,J7644,HCPCS,487980101,NDC,,,,inpatient,facility,2.5,UN,1.19,1.19,0.1,1.19,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,
IPRATROPIUM .02  NEB 2.5 ML,2500003490,CDM,637,RC,J7644,HCPCS,487980101,NDC,,,,outpatient,facility,2.5,UN,1.19,1.19,0.1,618.77,,0.69,,,percent of total billed charges,,,0.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.19,,,percent of total billed charges,,,0.45,,,fee schedule,,,0.43,,,fee schedule,,,,,,,,,0.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.07,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,fee schedule,,,0.32,,,fee schedule,,,,,,,,,618.77,,,per diem,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.46,,,fee schedule,,,0.21,,,fee schedule,,,1.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,0.36,,,fee schedule,,,0.22,,,fee schedule,,,,,,,,,,,,,,,0.2,,,fee schedule,,,0.26,,,fee schedule,,,0.14,,,fee schedule,,,0.39,,,fee schedule,,,1.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.84,,,percent of total billed charges,,
IPRATROPIUM .02  NEB 2.5 ML,2500003490,CDM,637,RC,J7644,HCPCS,487980101,NDC,496,EAPG,,outpatient,facility,2.5,UN,1.19,1.19,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IRON SUCROSE INJ 200MG,2500003496,CDM,636,RC,J1756,HCPCS,517231005,NDC,,,,inpatient,facility,10,ML,404.02,404.02,32.32,404.02,,,,,,,,,,,,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.62,,,percent of total billed charges,,,,,,,,,404.02,,,percent of total billed charges,,,223.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,368.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,404.02,,,percent of total billed charges,,,210.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.32,,,percent of total billed charges,,,404.02,,,percent of total billed charges,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.7,,,percent of total billed charges,,
IRON SUCROSE INJ 200MG,2500003496,CDM,636,RC,J1756,HCPCS,517231005,NDC,,,,outpatient,facility,10,ML,404.02,404.02,0.24,618.77,,235.95,,,percent of total billed charges,,,78.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,404.02,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,147.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,363.62,,,percent of total billed charges,,,,,,,,,404.02,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,310.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.66,,,percent of total billed charges,,,404.02,,,percent of total billed charges,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.06,,,percent of total billed charges,,,153.04,,,percent of total billed charges,,,209.24,,,percent of total billed charges,,,,,,,,,,,,,,,80.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,404.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,404.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.32,,,percent of total billed charges,,,404.02,,,percent of total billed charges,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,404.02,,,percent of total billed charges,,,404.02,,,percent of total billed charges,,,,,,,,,404.02,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.24,,,fee schedule,,,404.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,404.02,,,percent of total billed charges,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,283.7,,,percent of total billed charges,,
IRON SUCROSE INJ 200MG,2500003496,CDM,636,RC,J1756,HCPCS,517231005,NDC,435,EAPG,,outpatient,facility,10,ML,404.02,404.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METFORMIN 500MG ER.24H,2500003499,CDM,637,RC,6068764001,NDC,,,,,,inpatient,facility,500,UN,2.04,2.04,0.16,2.04,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,
METFORMIN 500MG ER.24H,2500003499,CDM,637,RC,6068764001,NDC,,,,,,outpatient,facility,500,UN,2.04,2.04,0.16,618.77,,1.19,,,percent of total billed charges,,,0.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.04,,,percent of total billed charges,,,1.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.84,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.75,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,2.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,2.04,,,fee schedule,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,2.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.43,,,percent of total billed charges,,
METFORMIN 500MG ER.24H,2500003499,CDM,637,RC,6068764001,NDC,999,EAPG,,,,outpatient,facility,500,UN,2.04,2.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
C1 ESTERASE INHIBITOR 500 UNIT,2500003500,CDM,636,RC,J0597,HCPCS,6383382502,NDC,,,,inpatient,facility,500,UN,13425.06,13425.06,1074,13425.06,,,,,,,,,,,,,,13425.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12082.55,,,percent of total billed charges,,,,,,,,,13425.06,,,percent of total billed charges,,,7432.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12249.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13425.06,,,percent of total billed charges,,,,,,,,,,,,,,,13425.06,,,percent of total billed charges,,,6999.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2685.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1074,,,percent of total billed charges,,,13425.06,,,percent of total billed charges,,,13425.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13425.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9427.08,,,percent of total billed charges,,
C1 ESTERASE INHIBITOR 500 UNIT,2500003500,CDM,636,RC,J0597,HCPCS,6383382502,NDC,,,,outpatient,facility,500,UN,13425.06,13425.06,41.48,13425.06,,7840.24,,,percent of total billed charges,,,,,,,,,13425.06,,,percent of total billed charges,,,80.1,,,fee schedule,,,77.19,,,fee schedule,,,,,,,,,77.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,13425.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12082.55,,,percent of total billed charges,,,,,,,,,13425.06,,,percent of total billed charges,,,9091.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10310.45,,,percent of total billed charges,,,,,,,,,,,,,,,64.36,,,fee schedule,,,64.36,,,fee schedule,,,,,,,,,618.77,,,per diem,,,13425.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6999.83,,,percent of total billed charges,,,13425.06,,,percent of total billed charges,,,13425.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10203.05,,,percent of total billed charges,,,5085.41,,,percent of total billed charges,,,6952.84,,,percent of total billed charges,,,,,,,,,,,,,,,2685.01,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,134.14,,,fee schedule,,,59.81,,,fee schedule,,,,,,,,,,,,,,,1074,,,percent of total billed charges,,,13425.06,,,percent of total billed charges,,,13425.06,,,percent of total billed charges,,,,,,,,,,,,,,,13425.06,,,percent of total billed charges,,,13425.06,,,percent of total billed charges,,,,,,,,,13425.06,,,fee schedule,,,63.82,,,fee schedule,,,,,,,,,,,,,,,56.12,,,fee schedule,,,74.83,,,fee schedule,,,41.48,,,fee schedule,,,70.32,,,fee schedule,,,13425.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13425.06,,,percent of total billed charges,,,13425.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6712.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9427.08,,,percent of total billed charges,,
C1 ESTERASE INHIBITOR 500 UNIT,2500003500,CDM,636,RC,J0597,HCPCS,6383382502,NDC,9269,APC,,outpatient,facility,500,UN,13425.06,13425.06,68.36,4913.57,,,,,,,,74.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,72.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.18,,,fee schedule,,,,,,,,,4913.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,72.46,,,fee schedule,,,,,,,,,,,,,,,72.46,,,fee schedule,,,76.08,,,fee schedule,,,,,,,,,72.46,,,fee schedule,,,72.46,,,fee schedule,,,76.08,,,fee schedule,,,,,,,,,,,,,,,105.07,,,fee schedule,,,,,,,,,,,,,,,72.46,,,fee schedule,,,,,,,,,,,,,,,69.56,,,fee schedule,,,77.53,,,fee schedule,,,76.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.46,,,fee schedule,,,72.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,75.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,90.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,72.46,,,fee schedule,,,72.46,,,fee schedule,,,,,,,,,,,,,,,72.46,,,fee schedule,,,,,,,,,,,,,,,72.46,,,fee schedule,,,74.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.36,,,fee schedule,,,72.46,,,fee schedule,,,75.36,,,fee schedule,,,72.46,,,fee schedule,,,,,,,,,72.46,,,fee schedule,,,,,,,,,72.46,,,fee schedule,,,,,,,,
C1 ESTERASE INHIBITOR 500 UNIT,2500003500,CDM,636,RC,J0597,HCPCS,6383382502,NDC,463,EAPG,,outpatient,facility,500,UN,13425.06,13425.06,6846.71,10037.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10037.28,,,fee schedule,,,6846.71,,,fee schedule,,,8923.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6846.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6846.71,,,fee schedule,,,6846.71,,,fee schedule,,,6846.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6846.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6846.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PNEUMOC 20-VAL CONJ-DIP CRM/PF,2500003521,CDM,636,RC,90677,CPT,5200002,NDC,,,,inpatient,facility,0.5,UN,887.73,887.73,71.02,887.73,,,,,,,,,,,,,,887.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,798.96,,,percent of total billed charges,,,,,,,,,887.73,,,percent of total billed charges,,,491.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,809.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,887.73,,,percent of total billed charges,,,,,,,,,,,,,,,887.73,,,percent of total billed charges,,,462.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.02,,,percent of total billed charges,,,887.73,,,percent of total billed charges,,,887.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,887.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,623.36,,,percent of total billed charges,,
PNEUMOC 20-VAL CONJ-DIP CRM/PF,2500003521,CDM,636,RC,90677,CPT,5200002,NDC,,,,outpatient,facility,0.5,UN,887.73,887.73,71.02,887.73,,518.43,,,percent of total billed charges,,,259.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,887.73,,,percent of total billed charges,,,352.28,,,fee schedule,,,339.47,,,fee schedule,,,252.29,,,fee schedule,,,339.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,887.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,254.81,,,fee schedule,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,252.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,798.96,,,percent of total billed charges,,,252.29,,,fee schedule,,,887.73,,,percent of total billed charges,,,601.17,,,percent of total billed charges,,,264.9,,,fee schedule,,,264.9,,,fee schedule,,,,,,,,,252.29,,,fee schedule,,,252.29,,,fee schedule,,,264.9,,,fee schedule,,,681.78,,,percent of total billed charges,,,,,,,,,365.82,,,fee schedule,,,289.38,,,fee schedule,,,289.38,,,fee schedule,,,259.86,,,fee schedule,,,618.77,,,per diem,,,887.73,,,percent of total billed charges,,,243.46,,,fee schedule,,,269.95,,,fee schedule,,,270.31,,,fee schedule,,,462.86,,,percent of total billed charges,,,887.73,,,percent of total billed charges,,,887.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,252.29,,,fee schedule,,,252.29,,,fee schedule,,,674.67,,,percent of total billed charges,,,336.27,,,percent of total billed charges,,,459.76,,,percent of total billed charges,,,,,,,,,267.74,,,fee schedule,,,177.55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,626.17,,,fee schedule,,,279.18,,,fee schedule,,,315.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,315.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,71.02,,,percent of total billed charges,,,887.73,,,percent of total billed charges,,,887.73,,,percent of total billed charges,,,252.29,,,fee schedule,,,252.29,,,fee schedule,,,887.73,,,percent of total billed charges,,,887.73,,,percent of total billed charges,,,252.29,,,fee schedule,,,298.04,,,fee schedule,,,297.91,,,fee schedule,,,252.29,,,fee schedule,,,259.86,,,fee schedule,,,261.97,,,fee schedule,,,349.29,,,fee schedule,,,193.64,,,fee schedule,,,309.29,,,fee schedule,,,887.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,887.73,,,percent of total billed charges,,,887.73,,,percent of total billed charges,,,273,,,fee schedule,,,252.29,,,fee schedule,,,269.02,,,fee schedule,,,252.29,,,fee schedule,,,252.29,,,fee schedule,,,257.44,,,fee schedule,,,443.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,257.44,,,fee schedule,,,623.36,,,percent of total billed charges,,
PNEUMOC 20-VAL CONJ-DIP CRM/PF,2500003521,CDM,636,RC,90677,CPT,5200002,NDC,415,EAPG,,outpatient,facility,0.5,UN,887.73,887.73,86.56,126.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.9,,,fee schedule,,,86.56,,,fee schedule,,,112.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.56,,,fee schedule,,,86.56,,,fee schedule,,,86.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,86.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROTHROMBIN COMP CONC 500U,2500003523,CDM,636,RC,J7168,HCPCS,6383339601,NDC,,,,inpatient,facility,20,ML,3606.96,3606.96,288.56,3606.96,,,,,,,,,,,,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3246.26,,,percent of total billed charges,,,,,,,,,3606.96,,,percent of total billed charges,,,1996.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3290.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,3606.96,,,percent of total billed charges,,,1880.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288.56,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2532.81,,,percent of total billed charges,,
PROTHROMBIN COMP CONC 500U,2500003523,CDM,636,RC,J7168,HCPCS,6383339601,NDC,,,,outpatient,facility,20,ML,3606.96,3606.96,1.42,3606.96,,2106.46,,,percent of total billed charges,,,,,,,,,3606.96,,,percent of total billed charges,,,4.02,,,fee schedule,,,3.87,,,fee schedule,,,,,,,,,3.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3246.26,,,percent of total billed charges,,,,,,,,,3606.96,,,percent of total billed charges,,,2442.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2770.15,,,percent of total billed charges,,,,,,,,,,,,,,,3.04,,,fee schedule,,,3.04,,,fee schedule,,,,,,,,,618.77,,,per diem,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1880.67,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2741.29,,,percent of total billed charges,,,1366.32,,,percent of total billed charges,,,1868.04,,,percent of total billed charges,,,,,,,,,,,,,,,721.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.61,,,fee schedule,,,2.06,,,fee schedule,,,,,,,,,,,,,,,288.56,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,3606.96,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,,,,,,,3606.96,,,fee schedule,,,2.19,,,fee schedule,,,,,,,,,,,,,,,1.93,,,fee schedule,,,2.57,,,fee schedule,,,1.42,,,fee schedule,,,2705.22,,,percent of total billed charges,,,3606.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3606.96,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1803.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2532.81,,,percent of total billed charges,,
PROTHROMBIN COMP CONC 500U,2500003523,CDM,636,RC,J7168,HCPCS,6383339601,NDC,9132,APC,,outpatient,facility,20,ML,3606.96,3606.96,2.12,1320.15,,,,,,,,2.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,2.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,fee schedule,,,,,,,,,1320.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,2.21,,,fee schedule,,,,,,,,,,,,,,,2.21,,,fee schedule,,,2.32,,,fee schedule,,,,,,,,,2.21,,,fee schedule,,,2.21,,,fee schedule,,,2.32,,,fee schedule,,,,,,,,,,,,,,,3.2,,,fee schedule,,,,,,,,,,,,,,,2.21,,,fee schedule,,,,,,,,,,,,,,,2.12,,,fee schedule,,,2.36,,,fee schedule,,,2.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,fee schedule,,,2.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,2.21,,,fee schedule,,,2.21,,,fee schedule,,,,,,,,,,,,,,,2.21,,,fee schedule,,,,,,,,,,,,,,,2.21,,,fee schedule,,,2.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,fee schedule,,,2.21,,,fee schedule,,,2.3,,,fee schedule,,,2.21,,,fee schedule,,,,,,,,,2.21,,,fee schedule,,,,,,,,,2.21,,,fee schedule,,,,,,,,
PROTHROMBIN COMP CONC 500U,2500003523,CDM,636,RC,J7168,HCPCS,6383339601,NDC,461,EAPG,,outpatient,facility,20,ML,3606.96,3606.96,2211.17,3241.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3241.58,,,fee schedule,,,2211.17,,,fee schedule,,,2881.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2211.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2211.17,,,fee schedule,,,2211.17,,,fee schedule,,,2211.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2211.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2211.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYALURONATE SOD 60 MG/3 ML SYR,2500003527,CDM,636,RC,J7318,HCPCS,8913020201,NDC,,,,inpatient,facility,3,ML,3547.5,3547.5,283.8,3547.5,,,,,,,,,,,,,,3547.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3192.75,,,percent of total billed charges,,,,,,,,,3547.5,,,percent of total billed charges,,,1963.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3236.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3547.5,,,percent of total billed charges,,,,,,,,,,,,,,,3547.5,,,percent of total billed charges,,,1849.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,709.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,3547.5,,,percent of total billed charges,,,3547.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3547.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2491.05,,,percent of total billed charges,,
HYALURONATE SOD 60 MG/3 ML SYR,2500003527,CDM,636,RC,J7318,HCPCS,8913020201,NDC,,,,outpatient,facility,3,ML,3547.5,3547.5,6.14,3547.5,,2071.74,,,percent of total billed charges,,,,,,,,,3547.5,,,percent of total billed charges,,,7.87,,,fee schedule,,,7.59,,,fee schedule,,,,,,,,,7.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3547.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3192.75,,,percent of total billed charges,,,,,,,,,3547.5,,,percent of total billed charges,,,2402.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2724.48,,,percent of total billed charges,,,,,,,,,,,,,,,6.14,,,fee schedule,,,6.14,,,fee schedule,,,,,,,,,618.77,,,per diem,,,3547.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1849.67,,,percent of total billed charges,,,3547.5,,,percent of total billed charges,,,3547.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2696.1,,,percent of total billed charges,,,1343.79,,,percent of total billed charges,,,1837.25,,,percent of total billed charges,,,,,,,,,,,,,,,709.5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,20.46,,,fee schedule,,,9.12,,,fee schedule,,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,3547.5,,,percent of total billed charges,,,3547.5,,,percent of total billed charges,,,,,,,,,,,,,,,3547.5,,,percent of total billed charges,,,3547.5,,,percent of total billed charges,,,,,,,,,3547.5,,,fee schedule,,,9.73,,,fee schedule,,,,,,,,,,,,,,,8.56,,,fee schedule,,,11.41,,,fee schedule,,,6.32,,,fee schedule,,,6.92,,,fee schedule,,,3547.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3547.5,,,percent of total billed charges,,,3547.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1773.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2491.05,,,percent of total billed charges,,
HYALURONATE SOD 60 MG/3 ML SYR,2500003527,CDM,636,RC,J7318,HCPCS,8913020201,NDC,9174,APC,,outpatient,facility,3,ML,3547.5,3547.5,6.43,1298.38,,,,,,,,6.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.77,,,fee schedule,,,,,,,,,1298.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,6.7,,,fee schedule,,,,,,,,,,,,,,,6.7,,,fee schedule,,,7.04,,,fee schedule,,,,,,,,,6.7,,,fee schedule,,,6.7,,,fee schedule,,,7.04,,,fee schedule,,,,,,,,,,,,,,,9.72,,,fee schedule,,,,,,,,,,,,,,,6.7,,,fee schedule,,,,,,,,,,,,,,,6.43,,,fee schedule,,,7.17,,,fee schedule,,,7.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.7,,,fee schedule,,,6.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.7,,,fee schedule,,,6.7,,,fee schedule,,,,,,,,,,,,,,,6.7,,,fee schedule,,,,,,,,,,,,,,,6.7,,,fee schedule,,,6.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7,,,fee schedule,,,6.7,,,fee schedule,,,6.97,,,fee schedule,,,6.7,,,fee schedule,,,,,,,,,6.7,,,fee schedule,,,,,,,,,6.7,,,fee schedule,,,,,,,,
HYALURONATE SOD 60 MG/3 ML SYR,2500003527,CDM,636,RC,J7318,HCPCS,8913020201,NDC,439,EAPG,,outpatient,facility,3,ML,3547.5,3547.5,767.47,1125.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.11,,,fee schedule,,,767.47,,,fee schedule,,,1000.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,767.47,,,fee schedule,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INDOMETHACIN 100 MG SUPP,2500003530,CDM,637,RC,7370214071,NDC,,,,,,inpatient,facility,100,UN,990,990,79.2,990,,,,,,,,,,,,,,990,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,891,,,percent of total billed charges,,,,,,,,,990,,,percent of total billed charges,,,548.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,990,,,percent of total billed charges,,,,,,,,,,,,,,,990,,,percent of total billed charges,,,516.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,990,,,percent of total billed charges,,,990,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,990,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,695.18,,,percent of total billed charges,,
INDOMETHACIN 100 MG SUPP,2500003530,CDM,637,RC,7370214071,NDC,,,,,,outpatient,facility,100,UN,990,990,79.2,990,,578.16,,,percent of total billed charges,,,193.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,990,,,percent of total billed charges,,,871.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,871.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,871.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,990,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,362.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,891,,,percent of total billed charges,,,,,,,,,990,,,percent of total billed charges,,,670.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,760.32,,,percent of total billed charges,,,,,,,,,,,,,,,534.6,,,percent of total billed charges,,,534.6,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,990,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,516.19,,,percent of total billed charges,,,990,,,percent of total billed charges,,,990,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,752.4,,,percent of total billed charges,,,375.01,,,percent of total billed charges,,,512.72,,,percent of total billed charges,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,366.3,,,percent of total billed charges,,,366.3,,,percent of total billed charges,,,990,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,990,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,79.2,,,percent of total billed charges,,,990,,,percent of total billed charges,,,990,,,percent of total billed charges,,,,,,,,,,,,,,,990,,,percent of total billed charges,,,990,,,percent of total billed charges,,,,,,,,,990,,,fee schedule,,,920.9,,,percent of total billed charges,,,,,,,,,,,,,,,920.9,,,percent of total billed charges,,,920.9,,,percent of total billed charges,,,920.9,,,percent of total billed charges,,,742.5,,,percent of total billed charges,,,990,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,990,,,percent of total billed charges,,,990,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,695.18,,,percent of total billed charges,,
INDOMETHACIN 100 MG SUPP,2500003530,CDM,637,RC,7370214071,NDC,999,EAPG,,,,outpatient,facility,100,UN,990,990,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
"COVID-19 VAC 30MCG/0.3ML BIVAL	",2500003552,CDM,,,,,,,,,,inpatient,facility,1,UN,0.03,0.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
"COVID-19 VAC 30MCG/0.3ML BIVAL	",2500003552,CDM,,,,,,,,,,outpatient,facility,1,UN,0.03,0.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COVID VAC (NOVAVAX) 5MCG/0.5ML,2500003566,CDM,636,RC,91304,CPT,,,,,,inpatient,facility,,,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
COVID VAC (NOVAVAX) 5MCG/0.5ML,2500003566,CDM,636,RC,91304,CPT,,,,,,outpatient,facility,,,0.01,0.01,0.01,618.77,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,175.18,,,fee schedule,,,168.81,,,fee schedule,,,,,,,,,168.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,618.77,,,per diem,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.01,,,percent of total billed charges,,
COVID VAC (NOVAVAX) 5MCG/0.5ML,2500003566,CDM,636,RC,91304,CPT,414,EAPG,,,,outpatient,facility,,,0.01,0.01,23.83,34.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.93,,,fee schedule,,,23.83,,,fee schedule,,,31.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPINEPHRINE 10 MG/10 ML INJ,2500003571,CDM,636,RC,J0171,HCPCS,5428812001,NDC,,,,inpatient,facility,10,ML,313.5,313.5,25.08,313.5,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.15,,,percent of total billed charges,,,,,,,,,313.5,,,percent of total billed charges,,,173.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,286.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,163.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.08,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.14,,,percent of total billed charges,,
EPINEPHRINE 10 MG/10 ML INJ,2500003571,CDM,636,RC,J0171,HCPCS,5428812001,NDC,,,,outpatient,facility,10,ML,313.5,313.5,0.84,618.77,,183.08,,,percent of total billed charges,,,61.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,313.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,114.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,282.15,,,percent of total billed charges,,,,,,,,,313.5,,,percent of total billed charges,,,212.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,163.46,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.26,,,percent of total billed charges,,,118.75,,,percent of total billed charges,,,162.36,,,percent of total billed charges,,,,,,,,,,,,,,,62.7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,313.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,313.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.08,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,313.5,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.84,,,fee schedule,,,313.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,220.14,,,percent of total billed charges,,
EPINEPHRINE 10 MG/10 ML INJ,2500003571,CDM,636,RC,J0171,HCPCS,5428812001,NDC,496,EAPG,,outpatient,facility,10,ML,313.5,313.5,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FACTOR IX HUM (RECOM) 1000U,2500003598,CDM,636,RC,J7195,HCPCS,5839463503,NDC,,,,inpatient,facility,1000,UN,3281.85,3281.85,262.55,3281.85,,,,,,,,,,,,,,3281.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.66,,,percent of total billed charges,,,,,,,,,3281.85,,,percent of total billed charges,,,1816.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2994.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3281.85,,,percent of total billed charges,,,,,,,,,,,,,,,3281.85,,,percent of total billed charges,,,1711.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,656.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.55,,,percent of total billed charges,,,3281.85,,,percent of total billed charges,,,3281.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3281.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2304.52,,,percent of total billed charges,,
FACTOR IX HUM (RECOM) 1000U,2500003598,CDM,636,RC,J7195,HCPCS,5839463503,NDC,,,,outpatient,facility,1000,UN,3281.85,3281.85,1.11,3281.85,,1916.6,,,percent of total billed charges,,,,,,,,,3281.85,,,percent of total billed charges,,,2.17,,,fee schedule,,,2.1,,,fee schedule,,,,,,,,,2.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3281.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2953.66,,,percent of total billed charges,,,,,,,,,3281.85,,,percent of total billed charges,,,2222.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2520.46,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,fee schedule,,,1.41,,,fee schedule,,,,,,,,,618.77,,,per diem,,,3281.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1711.16,,,percent of total billed charges,,,3281.85,,,percent of total billed charges,,,3281.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2494.21,,,percent of total billed charges,,,1243.16,,,percent of total billed charges,,,1699.67,,,percent of total billed charges,,,,,,,,,,,,,,,656.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.6,,,fee schedule,,,1.6,,,fee schedule,,,,,,,,,,,,,,,262.55,,,percent of total billed charges,,,3281.85,,,percent of total billed charges,,,3281.85,,,percent of total billed charges,,,,,,,,,,,,,,,3281.85,,,percent of total billed charges,,,3281.85,,,percent of total billed charges,,,,,,,,,1.84,,,fee schedule,,,1.71,,,fee schedule,,,,,,,,,,,,,,,1.51,,,fee schedule,,,2.01,,,fee schedule,,,1.11,,,fee schedule,,,1.9,,,fee schedule,,,3281.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3281.85,,,percent of total billed charges,,,3281.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1640.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2304.52,,,percent of total billed charges,,
FACTOR IX HUM (RECOM) 1000U,2500003598,CDM,636,RC,J7195,HCPCS,5839463503,NDC,932,APC,,outpatient,facility,1000,UN,3281.85,3281.85,1.77,2.67,,,,,,,,1.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.86,,,fee schedule,,,,,,,,,1.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1.84,,,fee schedule,,,,,,,,,,,,,,,1.84,,,fee schedule,,,1.93,,,fee schedule,,,,,,,,,1.84,,,fee schedule,,,1.84,,,fee schedule,,,1.93,,,fee schedule,,,,,,,,,,,,,,,2.67,,,fee schedule,,,,,,,,,,,,,,,1.84,,,fee schedule,,,,,,,,,,,,,,,1.77,,,fee schedule,,,1.97,,,fee schedule,,,1.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,fee schedule,,,1.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1.84,,,fee schedule,,,1.84,,,fee schedule,,,,,,,,,,,,,,,1.84,,,fee schedule,,,,,,,,,,,,,,,1.84,,,fee schedule,,,1.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,fee schedule,,,1.84,,,fee schedule,,,1.91,,,fee schedule,,,1.84,,,fee schedule,,,1.81,,,fee schedule,,,1.84,,,fee schedule,,,,,,,,,1.84,,,fee schedule,,,,,,,,
FACTOR IX HUM (RECOM) 1000U,2500003598,CDM,636,RC,J7195,HCPCS,5839463503,NDC,999,EAPG,,outpatient,facility,1000,UN,3281.85,3281.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESOMEPRAZOLE 40MG PKT,2500003617,CDM,637,RC,6909752934,NDC,,,,,,inpatient,facility,40,UN,32.21,32.21,2.58,32.21,,,,,,,,,,,,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.99,,,percent of total billed charges,,,,,,,,,32.21,,,percent of total billed charges,,,17.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,32.21,,,percent of total billed charges,,,16.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.62,,,percent of total billed charges,,
ESOMEPRAZOLE 40MG PKT,2500003617,CDM,637,RC,6909752934,NDC,,,,,,outpatient,facility,40,UN,32.21,32.21,2.58,618.77,,18.81,,,percent of total billed charges,,,6.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,32.21,,,percent of total billed charges,,,28.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,28.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,28.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,28.99,,,percent of total billed charges,,,,,,,,,32.21,,,percent of total billed charges,,,21.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.74,,,percent of total billed charges,,,,,,,,,,,,,,,17.39,,,percent of total billed charges,,,17.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.79,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.48,,,percent of total billed charges,,,12.2,,,percent of total billed charges,,,16.68,,,percent of total billed charges,,,,,,,,,,,,,,,6.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,11.92,,,percent of total billed charges,,,11.92,,,percent of total billed charges,,,32.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.58,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,32.21,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,,,,,,,32.21,,,fee schedule,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,24.16,,,percent of total billed charges,,,32.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,32.21,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.11,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,22.62,,,percent of total billed charges,,
ESOMEPRAZOLE 40MG PKT,2500003617,CDM,637,RC,6909752934,NDC,999,EAPG,,,,outpatient,facility,40,UN,32.21,32.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LABETALOL HCL 20MG/4MG INJ,2500003618,CDM,250,RC,J3490,HCPCS,3600032010,NDC,,,,inpatient,facility,4,UN,13.93,13.93,1.11,13.93,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.54,,,percent of total billed charges,,,,,,,,,13.93,,,percent of total billed charges,,,7.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,7.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,
LABETALOL HCL 20MG/4MG INJ,2500003618,CDM,250,RC,J3490,HCPCS,3600032010,NDC,,,,outpatient,facility,4,UN,13.93,13.93,1.11,618.77,,8.14,,,percent of total billed charges,,,2.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.93,,,percent of total billed charges,,,12.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.54,,,percent of total billed charges,,,,,,,,,13.93,,,percent of total billed charges,,,9.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.7,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.26,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.59,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,7.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.79,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,13.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.11,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,13.93,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,10.45,,,percent of total billed charges,,,13.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.78,,,percent of total billed charges,,
LABETALOL HCL 20MG/4MG INJ,2500003618,CDM,250,RC,J3490,HCPCS,3600032010,NDC,435,EAPG,,outpatient,facility,4,UN,13.93,13.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYALURONIDASE 15 UNIT/ML INJ,2500003619,CDM,636,RC,J3470,HCPCS,1865711704,NDC,,,,inpatient,facility,1,UN,9.21,9.21,0.74,9.21,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.29,,,percent of total billed charges,,,,,,,,,9.21,,,percent of total billed charges,,,5.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,4.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.47,,,percent of total billed charges,,
HYALURONIDASE 15 UNIT/ML INJ,2500003619,CDM,636,RC,J3470,HCPCS,1865711704,NDC,,,,outpatient,facility,1,UN,9.21,9.21,0.74,618.77,,5.38,,,percent of total billed charges,,,1.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.21,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.29,,,percent of total billed charges,,,,,,,,,9.21,,,percent of total billed charges,,,6.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.8,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7,,,percent of total billed charges,,,3.49,,,percent of total billed charges,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,9.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.74,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,,,,,,,9.21,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,9.21,,,fee schedule,,,9.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.47,,,percent of total billed charges,,
HYALURONIDASE 15 UNIT/ML INJ,2500003619,CDM,636,RC,J3470,HCPCS,1865711704,NDC,436,EAPG,,outpatient,facility,1,UN,9.21,9.21,126.95,186.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.11,,,fee schedule,,,126.95,,,fee schedule,,,165.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHOTREXATE ORAL 2.5 MG,2500003630,CDM,637,RC,J8610,HCPCS,6838277501,NDC,,,,inpatient,facility,2.5,UN,11.74,11.74,0.94,11.74,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.57,,,percent of total billed charges,,,,,,,,,11.74,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.24,,,percent of total billed charges,,
METHOTREXATE ORAL 2.5 MG,2500003630,CDM,637,RC,J8610,HCPCS,6838277501,NDC,,,,outpatient,facility,2.5,UN,11.74,11.74,0.24,618.77,,0.24,,,fee schedule,,,2.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.74,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.57,,,percent of total billed charges,,,,,,,,,11.74,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.92,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,6.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,11.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.94,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,,,,,,,11.74,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.25,,,fee schedule,,,11.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.74,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.24,,,percent of total billed charges,,
METHOTREXATE ORAL 2.5 MG,2500003630,CDM,637,RC,J8610,HCPCS,6838277501,NDC,999,EAPG,,outpatient,facility,2.5,UN,11.74,11.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACITRETIN 10 MG CAPSULE,2500003632,CDM,637,RC,378702093,NDC,,,,,,inpatient,facility,10,UN,102.96,102.96,8.24,102.96,,,,,,,,,,,,,,102.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.66,,,percent of total billed charges,,,,,,,,,102.96,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.96,,,percent of total billed charges,,,,,,,,,,,,,,,102.96,,,percent of total billed charges,,,53.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.24,,,percent of total billed charges,,,102.96,,,percent of total billed charges,,,102.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,102.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.3,,,percent of total billed charges,,
ACITRETIN 10 MG CAPSULE,2500003632,CDM,637,RC,378702093,NDC,,,,,,outpatient,facility,10,UN,102.96,102.96,8.24,618.77,,60.13,,,percent of total billed charges,,,20.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,102.96,,,percent of total billed charges,,,90.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,90.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,90.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,102.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,37.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,92.66,,,percent of total billed charges,,,,,,,,,102.96,,,percent of total billed charges,,,69.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.07,,,percent of total billed charges,,,,,,,,,,,,,,,55.6,,,percent of total billed charges,,,55.6,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,102.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.68,,,percent of total billed charges,,,102.96,,,percent of total billed charges,,,102.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.25,,,percent of total billed charges,,,39,,,percent of total billed charges,,,53.32,,,percent of total billed charges,,,,,,,,,,,,,,,20.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,38.1,,,percent of total billed charges,,,38.1,,,percent of total billed charges,,,102.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,102.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.24,,,percent of total billed charges,,,102.96,,,percent of total billed charges,,,102.96,,,percent of total billed charges,,,,,,,,,,,,,,,102.96,,,percent of total billed charges,,,102.96,,,percent of total billed charges,,,,,,,,,102.96,,,fee schedule,,,95.77,,,percent of total billed charges,,,,,,,,,,,,,,,95.77,,,percent of total billed charges,,,95.77,,,percent of total billed charges,,,95.77,,,percent of total billed charges,,,77.22,,,percent of total billed charges,,,102.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,102.96,,,percent of total billed charges,,,102.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,72.3,,,percent of total billed charges,,
ACITRETIN 10 MG CAPSULE,2500003632,CDM,637,RC,378702093,NDC,999,EAPG,,,,outpatient,facility,10,UN,102.96,102.96,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIPHTHPERTUSS(ACELL)TET VAC,2500003633,CDM,636,RC,90715,CPT,5816084252,NDC,,,,inpatient,facility,0.5,UN,148.96,148.96,11.92,148.96,,,,,,,,,,,,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.06,,,percent of total billed charges,,,,,,,,,148.96,,,percent of total billed charges,,,82.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,148.96,,,percent of total billed charges,,,77.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.92,,,percent of total billed charges,,,148.96,,,percent of total billed charges,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.6,,,percent of total billed charges,,
DIPHTHPERTUSS(ACELL)TET VAC,2500003633,CDM,636,RC,90715,CPT,5816084252,NDC,,,,outpatient,facility,0.5,UN,148.96,148.96,11.92,618.77,,86.99,,,percent of total billed charges,,,29.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,148.96,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,54.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,134.06,,,percent of total billed charges,,,,,,,,,148.96,,,percent of total billed charges,,,100.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.67,,,percent of total billed charges,,,148.96,,,percent of total billed charges,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.21,,,percent of total billed charges,,,56.43,,,percent of total billed charges,,,77.15,,,percent of total billed charges,,,,,,,,,,,,,,,29.79,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,148.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,148.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.92,,,percent of total billed charges,,,148.96,,,percent of total billed charges,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,148.96,,,percent of total billed charges,,,148.96,,,percent of total billed charges,,,,,,,,,148.96,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,39.73,,,fee schedule,,,148.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,148.96,,,percent of total billed charges,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,104.6,,,percent of total billed charges,,
DIPHTHPERTUSS(ACELL)TET VAC,2500003633,CDM,636,RC,90715,CPT,5816084252,NDC,414,EAPG,,outpatient,facility,0.5,UN,148.96,148.96,23.83,34.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.93,,,fee schedule,,,23.83,,,fee schedule,,,31.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFAZOLIN 3 GM INJ,2500003647,CDM,636,RC,J0690,HCPCS,143914025,NDC,,,,inpatient,facility,3,UN,28.97,28.97,2.32,28.97,,,,,,,,,,,,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.07,,,percent of total billed charges,,,,,,,,,28.97,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,28.97,,,percent of total billed charges,,,15.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.34,,,percent of total billed charges,,
CEFAZOLIN 3 GM INJ,2500003647,CDM,636,RC,J0690,HCPCS,143914025,NDC,,,,outpatient,facility,3,UN,28.97,28.97,0.85,618.77,,16.92,,,percent of total billed charges,,,5.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,28.97,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26.07,,,percent of total billed charges,,,,,,,,,28.97,,,percent of total billed charges,,,19.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.1,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.02,,,percent of total billed charges,,,10.97,,,percent of total billed charges,,,15,,,percent of total billed charges,,,,,,,,,,,,,,,5.79,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,28.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.32,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,28.97,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,,,,,,,28.97,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,28.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,28.97,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.34,,,percent of total billed charges,,
CEFAZOLIN 3 GM INJ,2500003647,CDM,636,RC,J0690,HCPCS,143914025,NDC,496,EAPG,,outpatient,facility,3,UN,28.97,28.97,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYCODONE 10 MG TABLET,2500003656,CDM,637,RC,406851001,NDC,,,,,,inpatient,facility,10,UN,4.03,4.03,0.32,4.03,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,,,,,,,4.03,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.83,,,percent of total billed charges,,
OXYCODONE 10 MG TABLET,2500003656,CDM,637,RC,406851001,NDC,,,,,,outpatient,facility,10,UN,4.03,4.03,0.32,618.77,,2.35,,,percent of total billed charges,,,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.03,,,percent of total billed charges,,,3.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.63,,,percent of total billed charges,,,,,,,,,4.03,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.1,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,2.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.49,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,4.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.32,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,4.03,,,fee schedule,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,3.02,,,percent of total billed charges,,,4.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.03,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.83,,,percent of total billed charges,,
OXYCODONE 10 MG TABLET,2500003656,CDM,637,RC,406851001,NDC,999,EAPG,,,,outpatient,facility,10,UN,4.03,4.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCIUM GLUC/NS 1 GM/50 ML,2500003679,CDM,250,RC,J0613,HCPCS,4456762024,NDC,,,,inpatient,facility,50,UN,78.21,78.21,6.26,78.21,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,78.21,,,percent of total billed charges,,,43.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,40.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.92,,,percent of total billed charges,,
CALCIUM GLUC/NS 1 GM/50 ML,2500003679,CDM,250,RC,J0613,HCPCS,4456762024,NDC,,,,outpatient,facility,50,UN,78.21,78.21,0.09,618.77,,45.67,,,percent of total billed charges,,,15.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,78.21,,,percent of total billed charges,,,0.11,,,fee schedule,,,0.1,,,fee schedule,,,,,,,,,0.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,28.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,70.39,,,percent of total billed charges,,,,,,,,,78.21,,,percent of total billed charges,,,52.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.78,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.44,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,40.5,,,percent of total billed charges,,,,,,,,,,,,,,,15.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,78.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,78.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.26,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,,,,,,,78.21,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,78.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,78.21,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,54.92,,,percent of total billed charges,,
CALCIUM GLUC/NS 1 GM/50 ML,2500003679,CDM,250,RC,J0613,HCPCS,4456762024,NDC,999,EAPG,,outpatient,facility,50,UN,78.21,78.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUTICASONE/SALM 113/14MCG INH,2500003713,CDM,637,RC,93360882,NDC,,,,,,inpatient,facility,8,UN,506.29,506.29,40.5,506.29,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455.66,,,percent of total billed charges,,,,,,,,,506.29,,,percent of total billed charges,,,280.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,461.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,263.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.5,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.52,,,percent of total billed charges,,
FLUTICASONE/SALM 113/14MCG INH,2500003713,CDM,637,RC,93360882,NDC,,,,,,outpatient,facility,8,UN,506.29,506.29,40.5,618.77,,295.67,,,percent of total billed charges,,,98.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,506.29,,,percent of total billed charges,,,445.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,445.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,445.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,185.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,455.66,,,percent of total billed charges,,,,,,,,,506.29,,,percent of total billed charges,,,342.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.83,,,percent of total billed charges,,,,,,,,,,,,,,,273.4,,,percent of total billed charges,,,273.4,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,263.98,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.78,,,percent of total billed charges,,,191.78,,,percent of total billed charges,,,262.21,,,percent of total billed charges,,,,,,,,,,,,,,,101.26,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,187.33,,,percent of total billed charges,,,187.33,,,percent of total billed charges,,,506.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,506.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.5,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,506.29,,,fee schedule,,,470.95,,,percent of total billed charges,,,,,,,,,,,,,,,470.95,,,percent of total billed charges,,,470.95,,,percent of total billed charges,,,470.95,,,percent of total billed charges,,,379.72,,,percent of total billed charges,,,506.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,355.52,,,percent of total billed charges,,
FLUTICASONE/SALM 113/14MCG INH,2500003713,CDM,637,RC,93360882,NDC,999,EAPG,,,,outpatient,facility,8,UN,506.29,506.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUTICASONE/SALM 232/14MCG INH,2500003715,CDM,637,RC,93360982,NDC,,,,,,inpatient,facility,8,UN,506.29,506.29,40.5,506.29,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455.66,,,percent of total billed charges,,,,,,,,,506.29,,,percent of total billed charges,,,280.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,461.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,263.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.5,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.52,,,percent of total billed charges,,
FLUTICASONE/SALM 232/14MCG INH,2500003715,CDM,637,RC,93360982,NDC,,,,,,outpatient,facility,8,UN,506.29,506.29,40.5,618.77,,295.67,,,percent of total billed charges,,,98.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,506.29,,,percent of total billed charges,,,445.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,445.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,445.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,185.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,455.66,,,percent of total billed charges,,,,,,,,,506.29,,,percent of total billed charges,,,342.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.83,,,percent of total billed charges,,,,,,,,,,,,,,,273.4,,,percent of total billed charges,,,273.4,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,263.98,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.78,,,percent of total billed charges,,,191.78,,,percent of total billed charges,,,262.21,,,percent of total billed charges,,,,,,,,,,,,,,,101.26,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,187.33,,,percent of total billed charges,,,187.33,,,percent of total billed charges,,,506.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,506.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.5,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,506.29,,,fee schedule,,,470.95,,,percent of total billed charges,,,,,,,,,,,,,,,470.95,,,percent of total billed charges,,,470.95,,,percent of total billed charges,,,470.95,,,percent of total billed charges,,,379.72,,,percent of total billed charges,,,506.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,355.52,,,percent of total billed charges,,
FLUTICASONE/SALM 232/14MCG INH,2500003715,CDM,637,RC,93360982,NDC,999,EAPG,,,,outpatient,facility,8,UN,506.29,506.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUTICASONE FURO 200MCG 14 INH,2500003716,CDM,637,RC,173087614,NDC,,,,,,inpatient,facility,14,UN,30.69,30.69,2.46,30.69,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.62,,,percent of total billed charges,,,,,,,,,30.69,,,percent of total billed charges,,,16.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.55,,,percent of total billed charges,,
FLUTICASONE FURO 200MCG 14 INH,2500003716,CDM,637,RC,173087614,NDC,,,,,,outpatient,facility,14,UN,30.69,30.69,2.46,618.77,,17.92,,,percent of total billed charges,,,5.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,30.69,,,percent of total billed charges,,,27.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,27.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,27.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,27.62,,,percent of total billed charges,,,,,,,,,30.69,,,percent of total billed charges,,,20.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.57,,,percent of total billed charges,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,16.57,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.32,,,percent of total billed charges,,,11.63,,,percent of total billed charges,,,15.89,,,percent of total billed charges,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,11.36,,,percent of total billed charges,,,11.36,,,percent of total billed charges,,,30.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.46,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,,,,,,,30.69,,,fee schedule,,,28.55,,,percent of total billed charges,,,,,,,,,,,,,,,28.55,,,percent of total billed charges,,,28.55,,,percent of total billed charges,,,28.55,,,percent of total billed charges,,,23.02,,,percent of total billed charges,,,30.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,30.69,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,21.55,,,percent of total billed charges,,
FLUTICASONE FURO 200MCG 14 INH,2500003716,CDM,637,RC,173087614,NDC,999,EAPG,,,,outpatient,facility,14,UN,30.69,30.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUTICASONE FURO 100MCG 14 INH,2500003717,CDM,637,RC,173087410,NDC,,,,,,inpatient,facility,14,UN,22.94,22.94,1.84,22.94,,,,,,,,,,,,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.65,,,percent of total billed charges,,,,,,,,,22.94,,,percent of total billed charges,,,12.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,22.94,,,percent of total billed charges,,,11.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.11,,,percent of total billed charges,,
FLUTICASONE FURO 100MCG 14 INH,2500003717,CDM,637,RC,173087410,NDC,,,,,,outpatient,facility,14,UN,22.94,22.94,1.84,618.77,,13.4,,,percent of total billed charges,,,4.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,22.94,,,percent of total billed charges,,,20.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,20.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,20.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,20.65,,,percent of total billed charges,,,,,,,,,22.94,,,percent of total billed charges,,,15.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.62,,,percent of total billed charges,,,,,,,,,,,,,,,12.39,,,percent of total billed charges,,,12.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.96,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.43,,,percent of total billed charges,,,8.69,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.49,,,percent of total billed charges,,,8.49,,,percent of total billed charges,,,22.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.84,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,22.94,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,,,,,,,22.94,,,fee schedule,,,21.34,,,percent of total billed charges,,,,,,,,,,,,,,,21.34,,,percent of total billed charges,,,21.34,,,percent of total billed charges,,,21.34,,,percent of total billed charges,,,17.21,,,percent of total billed charges,,,22.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,22.94,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,16.11,,,percent of total billed charges,,
FLUTICASONE FURO 100MCG 14 INH,2500003717,CDM,637,RC,173087410,NDC,999,EAPG,,,,outpatient,facility,14,UN,22.94,22.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
UMECLIDINIUM 62.5 MCG 1 PUFF,2500003719,CDM,637,RC,173087310,NDC,,,,,,inpatient,facility,1,UN,38.94,38.94,3.12,38.94,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.05,,,percent of total billed charges,,,,,,,,,38.94,,,percent of total billed charges,,,21.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,20.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.34,,,percent of total billed charges,,
UMECLIDINIUM 62.5 MCG 1 PUFF,2500003719,CDM,637,RC,173087310,NDC,,,,,,outpatient,facility,1,UN,38.94,38.94,3.12,618.77,,22.74,,,percent of total billed charges,,,7.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,38.94,,,percent of total billed charges,,,34.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,34.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,34.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,14.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,35.05,,,percent of total billed charges,,,,,,,,,38.94,,,percent of total billed charges,,,26.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.91,,,percent of total billed charges,,,,,,,,,,,,,,,21.03,,,percent of total billed charges,,,21.03,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.3,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.59,,,percent of total billed charges,,,14.75,,,percent of total billed charges,,,20.17,,,percent of total billed charges,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,14.41,,,percent of total billed charges,,,14.41,,,percent of total billed charges,,,38.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,38.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.12,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,,,,,,,38.94,,,fee schedule,,,36.22,,,percent of total billed charges,,,,,,,,,,,,,,,36.22,,,percent of total billed charges,,,36.22,,,percent of total billed charges,,,36.22,,,percent of total billed charges,,,29.2,,,percent of total billed charges,,,38.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,38.94,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,27.34,,,percent of total billed charges,,
UMECLIDINIUM 62.5 MCG 1 PUFF,2500003719,CDM,637,RC,173087310,NDC,999,EAPG,,,,outpatient,facility,1,UN,38.94,38.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIRSEVIMAB-ALIP 50MG/0.5ML STA,2500003735,CDM,636,RC,90380,CPT,,,,,,inpatient,facility,,,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
NIRSEVIMAB-ALIP 50MG/0.5ML STA,2500003735,CDM,636,RC,90380,CPT,,,,,,outpatient,facility,,,0.01,0.01,0.01,700.36,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,700.36,,,fee schedule,,,674.88,,,fee schedule,,,,,,,,,674.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,618.77,,,per diem,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.01,,,percent of total billed charges,,
NIRSEVIMAB-ALIP 50MG/0.5ML STA,2500003735,CDM,636,RC,90380,CPT,444,EAPG,,,,outpatient,facility,,,0.01,0.01,1266.08,1856.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1856.07,,,fee schedule,,,1266.08,,,fee schedule,,,1650.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,1266.08,,,fee schedule,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIRSVIMAB-ALIP 100MG/ML STATE,2500003737,CDM,636,RC,90381,CPT,,,,,,inpatient,facility,,,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
NIRSVIMAB-ALIP 100MG/ML STATE,2500003737,CDM,636,RC,90381,CPT,,,,,,outpatient,facility,,,0.01,0.01,0.01,700.36,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,700.36,,,fee schedule,,,674.88,,,fee schedule,,,,,,,,,674.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,618.77,,,per diem,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.01,,,percent of total billed charges,,
NIRSVIMAB-ALIP 100MG/ML STATE,2500003737,CDM,636,RC,90381,CPT,444,EAPG,,,,outpatient,facility,,,0.01,0.01,1266.08,1856.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1856.07,,,fee schedule,,,1266.08,,,fee schedule,,,1650.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,1266.08,,,fee schedule,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBOXYMETHYLCELLULOSE SODIUM,2500003747,CDM,637,RC,23079815,NDC,,,,,,inpatient,facility,15,UN,27.69,27.69,2.22,27.69,,,,,,,,,,,,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.92,,,percent of total billed charges,,,,,,,,,27.69,,,percent of total billed charges,,,15.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,27.69,,,percent of total billed charges,,,14.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.44,,,percent of total billed charges,,
CARBOXYMETHYLCELLULOSE SODIUM,2500003747,CDM,637,RC,23079815,NDC,,,,,,outpatient,facility,15,UN,27.69,27.69,2.22,618.77,,16.17,,,percent of total billed charges,,,5.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,27.69,,,percent of total billed charges,,,24.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,24.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,24.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,24.92,,,percent of total billed charges,,,,,,,,,27.69,,,percent of total billed charges,,,18.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.27,,,percent of total billed charges,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.44,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.04,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,14.34,,,percent of total billed charges,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.25,,,percent of total billed charges,,,10.25,,,percent of total billed charges,,,27.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.22,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,27.69,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,,,,,,,27.69,,,fee schedule,,,25.76,,,percent of total billed charges,,,,,,,,,,,,,,,25.76,,,percent of total billed charges,,,25.76,,,percent of total billed charges,,,25.76,,,percent of total billed charges,,,20.77,,,percent of total billed charges,,,27.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,27.69,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,19.44,,,percent of total billed charges,,
CARBOXYMETHYLCELLULOSE SODIUM,2500003747,CDM,637,RC,23079815,NDC,999,EAPG,,,,outpatient,facility,15,UN,27.69,27.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMINO ACIDS 5 /D15W 2000 ML B,2500003756,CDM,258,RC,338109904,NDC,,,,,,inpatient,facility,2000,UN,265.32,265.32,21.23,265.32,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.79,,,percent of total billed charges,,,,,,,,,265.32,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,138.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.23,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.31,,,percent of total billed charges,,
AMINO ACIDS 5 /D15W 2000 ML B,2500003756,CDM,258,RC,338109904,NDC,,,,,,outpatient,facility,2000,UN,265.32,265.32,21.23,618.77,,154.95,,,percent of total billed charges,,,51.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,265.32,,,percent of total billed charges,,,233.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,233.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,233.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,97.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,238.79,,,percent of total billed charges,,,,,,,,,265.32,,,percent of total billed charges,,,179.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,203.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,138.34,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.64,,,percent of total billed charges,,,100.5,,,percent of total billed charges,,,137.41,,,percent of total billed charges,,,,,,,,,,,,,,,53.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,106.13,,,percent of total billed charges,,,106.13,,,percent of total billed charges,,,265.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,265.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.23,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,265.32,,,fee schedule,,,106.13,,,percent of total billed charges,,,,,,,,,,,,,,,106.13,,,percent of total billed charges,,,106.13,,,percent of total billed charges,,,106.13,,,percent of total billed charges,,,198.99,,,percent of total billed charges,,,265.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,186.31,,,percent of total billed charges,,
AMINO ACIDS 5 /D15W 2000 ML B,2500003756,CDM,258,RC,338109904,NDC,999,EAPG,,,,outpatient,facility,2000,UN,265.32,265.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EUCERIN 57 GM JAR,2500003759,CDM,637,RC,7214003868,NDC,,,,,,inpatient,facility,57,UN,16.61,16.61,1.33,16.61,,,,,,,,,,,,,,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,,,,,,,16.61,,,percent of total billed charges,,,9.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,16.61,,,percent of total billed charges,,,8.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,16.61,,,percent of total billed charges,,,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.66,,,percent of total billed charges,,
EUCERIN 57 GM JAR,2500003759,CDM,637,RC,7214003868,NDC,,,,,,outpatient,facility,57,UN,16.61,16.61,1.33,618.77,,9.7,,,percent of total billed charges,,,3.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.61,,,percent of total billed charges,,,14.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,14.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,14.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,14.95,,,percent of total billed charges,,,,,,,,,16.61,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.76,,,percent of total billed charges,,,,,,,,,,,,,,,8.97,,,percent of total billed charges,,,8.97,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.66,,,percent of total billed charges,,,16.61,,,percent of total billed charges,,,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.62,,,percent of total billed charges,,,6.29,,,percent of total billed charges,,,8.6,,,percent of total billed charges,,,,,,,,,,,,,,,3.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.15,,,percent of total billed charges,,,6.15,,,percent of total billed charges,,,16.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.33,,,percent of total billed charges,,,16.61,,,percent of total billed charges,,,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,16.61,,,percent of total billed charges,,,16.61,,,percent of total billed charges,,,,,,,,,16.61,,,fee schedule,,,15.45,,,percent of total billed charges,,,,,,,,,,,,,,,15.45,,,percent of total billed charges,,,15.45,,,percent of total billed charges,,,15.45,,,percent of total billed charges,,,12.46,,,percent of total billed charges,,,16.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.61,,,percent of total billed charges,,,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.66,,,percent of total billed charges,,
EUCERIN 57 GM JAR,2500003759,CDM,637,RC,7214003868,NDC,999,EAPG,,,,outpatient,facility,57,UN,16.61,16.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RSVPREF3 ANTIGN/AS01E/PF120 SS,2500003766,CDM,636,RC,90679,CPT,,,,,,inpatient,facility,,,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
RSVPREF3 ANTIGN/AS01E/PF120 SS,2500003766,CDM,636,RC,90679,CPT,,,,,,outpatient,facility,,,0.01,0.01,0.01,618.77,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,397.15,,,fee schedule,,,382.7,,,fee schedule,,,,,,,,,382.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,618.77,,,per diem,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.01,,,percent of total billed charges,,
RSVPREF3 ANTIGN/AS01E/PF120 SS,2500003766,CDM,636,RC,90679,CPT,414,EAPG,,,,outpatient,facility,,,0.01,0.01,23.83,34.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.93,,,fee schedule,,,23.83,,,fee schedule,,,31.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RSV VACCPREF A &PREF B/PF SS,2500003767,CDM,636,RC,90678,CPT,,,,,,inpatient,facility,,,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
RSV VACCPREF A &PREF B/PF SS,2500003767,CDM,636,RC,90678,CPT,,,,,,outpatient,facility,,,0.01,0.01,0.01,618.77,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,418.43,,,fee schedule,,,403.21,,,fee schedule,,,,,,,,,403.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,618.77,,,per diem,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.01,,,percent of total billed charges,,
RSV VACCPREF A &PREF B/PF SS,2500003767,CDM,636,RC,90678,CPT,414,EAPG,,,,outpatient,facility,,,0.01,0.01,23.83,34.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.93,,,fee schedule,,,23.83,,,fee schedule,,,31.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PCC (BALFAXAR) 1000 UNIT VIAL,2500003777,CDM,636,RC,J7165,HCPCS,6898226102,NDC,,,,inpatient,facility,40,UN,4550.83,4550.83,364.07,4550.83,,,,,,,,,,,,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4095.75,,,percent of total billed charges,,,,,,,,,4550.83,,,percent of total billed charges,,,2519.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4152.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,4550.83,,,percent of total billed charges,,,2372.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.07,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.59,,,percent of total billed charges,,
PCC (BALFAXAR) 1000 UNIT VIAL,2500003777,CDM,636,RC,J7165,HCPCS,6898226102,NDC,,,,outpatient,facility,40,UN,4550.83,4550.83,4.09,4550.83,,2657.68,,,percent of total billed charges,,,,,,,,,4550.83,,,percent of total billed charges,,,4.24,,,fee schedule,,,4.09,,,fee schedule,,,,,,,,,4.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4095.75,,,percent of total billed charges,,,,,,,,,4550.83,,,percent of total billed charges,,,3081.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3495.04,,,percent of total billed charges,,,,,,,,,,,,,,,2457.45,,,percent of total billed charges,,,2457.45,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2372.8,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3458.63,,,percent of total billed charges,,,1723.85,,,percent of total billed charges,,,2356.87,,,percent of total billed charges,,,,,,,,,,,,,,,910.17,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1683.81,,,percent of total billed charges,,,1683.81,,,percent of total billed charges,,,,,,,,,,,,,,,364.07,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,4550.83,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,,,,,,,4550.83,,,fee schedule,,,4233.18,,,percent of total billed charges,,,,,,,,,,,,,,,4233.18,,,percent of total billed charges,,,4233.18,,,percent of total billed charges,,,4233.18,,,percent of total billed charges,,,3413.12,,,percent of total billed charges,,,4550.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4550.83,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2275.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3195.59,,,percent of total billed charges,,
PCC (BALFAXAR) 1000 UNIT VIAL,2500003777,CDM,636,RC,J7165,HCPCS,6898226102,NDC,702,APC,,outpatient,facility,40,UN,4550.83,4550.83,1.73,1665.6,,,,,,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,fee schedule,,,,,,,,,1665.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.8,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,1.8,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,,,,,,,,2.61,,,fee schedule,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.73,,,fee schedule,,,1.93,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,1.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.8,,,fee schedule,,,1.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,fee schedule,,,1.8,,,fee schedule,,,1.87,,,fee schedule,,,1.8,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,,,,,,
PCC (BALFAXAR) 1000 UNIT VIAL,2500003777,CDM,636,RC,J7165,HCPCS,6898226102,NDC,461,EAPG,,outpatient,facility,40,UN,4550.83,4550.83,2211.17,3241.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3241.58,,,fee schedule,,,2211.17,,,fee schedule,,,2881.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2211.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2211.17,,,fee schedule,,,2211.17,,,fee schedule,,,2211.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2211.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2211.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PCC (BALFAXAR) 500 UNIT VIAL,2500003778,CDM,636,RC,J7165,HCPCS,6898226101,NDC,,,,inpatient,facility,20,UN,2362.93,2362.93,189.03,2362.93,,,,,,,,,,,,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.64,,,percent of total billed charges,,,,,,,,,2362.93,,,percent of total billed charges,,,1308.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,2362.93,,,percent of total billed charges,,,1232.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,472.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.03,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1659.25,,,percent of total billed charges,,
PCC (BALFAXAR) 500 UNIT VIAL,2500003778,CDM,636,RC,J7165,HCPCS,6898226101,NDC,,,,outpatient,facility,20,UN,2362.93,2362.93,4.09,2362.93,,1379.95,,,percent of total billed charges,,,,,,,,,2362.93,,,percent of total billed charges,,,4.24,,,fee schedule,,,4.09,,,fee schedule,,,,,,,,,4.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2126.64,,,percent of total billed charges,,,,,,,,,2362.93,,,percent of total billed charges,,,1600.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1814.73,,,percent of total billed charges,,,,,,,,,,,,,,,1275.98,,,percent of total billed charges,,,1275.98,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1232.03,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1795.83,,,percent of total billed charges,,,895.08,,,percent of total billed charges,,,1223.76,,,percent of total billed charges,,,,,,,,,,,,,,,472.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,874.28,,,percent of total billed charges,,,874.28,,,percent of total billed charges,,,,,,,,,,,,,,,189.03,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,2362.93,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,,,,,,,2362.93,,,fee schedule,,,2198,,,percent of total billed charges,,,,,,,,,,,,,,,2198,,,percent of total billed charges,,,2198,,,percent of total billed charges,,,2198,,,percent of total billed charges,,,1772.2,,,percent of total billed charges,,,2362.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2362.93,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1181.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1659.25,,,percent of total billed charges,,
PCC (BALFAXAR) 500 UNIT VIAL,2500003778,CDM,636,RC,J7165,HCPCS,6898226101,NDC,702,APC,,outpatient,facility,20,UN,2362.93,2362.93,1.73,864.83,,,,,,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,fee schedule,,,,,,,,,864.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.8,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,1.8,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,,,,,,,,2.61,,,fee schedule,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.73,,,fee schedule,,,1.93,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,1.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.8,,,fee schedule,,,1.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,fee schedule,,,1.8,,,fee schedule,,,1.87,,,fee schedule,,,1.8,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,,,,,,
PCC (BALFAXAR) 500 UNIT VIAL,2500003778,CDM,636,RC,J7165,HCPCS,6898226101,NDC,461,EAPG,,outpatient,facility,20,UN,2362.93,2362.93,2211.17,3241.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3241.58,,,fee schedule,,,2211.17,,,fee schedule,,,2881.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2211.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2211.17,,,fee schedule,,,2211.17,,,fee schedule,,,2211.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2211.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2211.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DROPERIDOL 5 MG/2 ML INJ,2500003797,CDM,636,RC,J1790,HCPCS,517970225,NDC,,,,inpatient,facility,2,UN,31.94,31.94,2.56,31.94,,,,,,,,,,,,,,31.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.75,,,percent of total billed charges,,,,,,,,,31.94,,,percent of total billed charges,,,17.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.94,,,percent of total billed charges,,,,,,,,,,,,,,,31.94,,,percent of total billed charges,,,16.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,31.94,,,percent of total billed charges,,,31.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.43,,,percent of total billed charges,,
DROPERIDOL 5 MG/2 ML INJ,2500003797,CDM,636,RC,J1790,HCPCS,517970225,NDC,,,,outpatient,facility,2,UN,31.94,31.94,2.56,618.77,,18.65,,,percent of total billed charges,,,6.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,31.94,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,31.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,28.75,,,percent of total billed charges,,,,,,,,,31.94,,,percent of total billed charges,,,21.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,31.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.65,,,percent of total billed charges,,,31.94,,,percent of total billed charges,,,31.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.27,,,percent of total billed charges,,,12.1,,,percent of total billed charges,,,16.54,,,percent of total billed charges,,,,,,,,,,,,,,,6.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,31.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.56,,,percent of total billed charges,,,31.94,,,percent of total billed charges,,,31.94,,,percent of total billed charges,,,,,,,,,,,,,,,31.94,,,percent of total billed charges,,,31.94,,,percent of total billed charges,,,,,,,,,31.94,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.83,,,fee schedule,,,31.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,31.94,,,percent of total billed charges,,,31.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,22.43,,,percent of total billed charges,,
DROPERIDOL 5 MG/2 ML INJ,2500003797,CDM,636,RC,J1790,HCPCS,517970225,NDC,496,EAPG,,outpatient,facility,2,UN,31.94,31.94,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPINEPHRINE 5 MG NEB,2500003816,CDM,636,RC,J0171,HCPCS,5428810310,NDC,,,,inpatient,facility,5,ML,288.75,288.75,23.1,288.75,,,,,,,,,,,,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.88,,,percent of total billed charges,,,,,,,,,288.75,,,percent of total billed charges,,,159.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,288.75,,,percent of total billed charges,,,150.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.1,,,percent of total billed charges,,,288.75,,,percent of total billed charges,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.76,,,percent of total billed charges,,
EPINEPHRINE 5 MG NEB,2500003816,CDM,636,RC,J0171,HCPCS,5428810310,NDC,,,,outpatient,facility,5,ML,288.75,288.75,0.84,618.77,,168.63,,,percent of total billed charges,,,56.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,288.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,105.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,259.88,,,percent of total billed charges,,,,,,,,,288.75,,,percent of total billed charges,,,195.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.55,,,percent of total billed charges,,,288.75,,,percent of total billed charges,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.45,,,percent of total billed charges,,,109.38,,,percent of total billed charges,,,149.54,,,percent of total billed charges,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,288.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,288.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.1,,,percent of total billed charges,,,288.75,,,percent of total billed charges,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,288.75,,,percent of total billed charges,,,288.75,,,percent of total billed charges,,,,,,,,,288.75,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.84,,,fee schedule,,,288.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,288.75,,,percent of total billed charges,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,202.76,,,percent of total billed charges,,
EPINEPHRINE 5 MG NEB,2500003816,CDM,636,RC,J0171,HCPCS,5428810310,NDC,496,EAPG,,outpatient,facility,5,ML,288.75,288.75,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPINEPHRINE 0.5 MG NEB,2500003817,CDM,636,RC,J0171,HCPCS,5428810310,NDC,,,,inpatient,facility,0.5,ML,13.12,13.12,1.05,13.12,,,,,,,,,,,,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.81,,,percent of total billed charges,,,,,,,,,13.12,,,percent of total billed charges,,,7.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,13.12,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,13.12,,,percent of total billed charges,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,
EPINEPHRINE 0.5 MG NEB,2500003817,CDM,636,RC,J0171,HCPCS,5428810310,NDC,,,,outpatient,facility,0.5,ML,13.12,13.12,0.84,618.77,,7.66,,,percent of total billed charges,,,2.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.12,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.81,,,percent of total billed charges,,,,,,,,,13.12,,,percent of total billed charges,,,8.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.84,,,percent of total billed charges,,,13.12,,,percent of total billed charges,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.97,,,percent of total billed charges,,,4.97,,,percent of total billed charges,,,6.79,,,percent of total billed charges,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,13.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.05,,,percent of total billed charges,,,13.12,,,percent of total billed charges,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,13.12,,,percent of total billed charges,,,13.12,,,percent of total billed charges,,,,,,,,,13.12,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.84,,,fee schedule,,,13.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.12,,,percent of total billed charges,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.21,,,percent of total billed charges,,
EPINEPHRINE 0.5 MG NEB,2500003817,CDM,636,RC,J0171,HCPCS,5428810310,NDC,496,EAPG,,outpatient,facility,0.5,ML,13.12,13.12,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INFLU (FLUZONE TRIV) PF 0.5ML,2500003841,CDM,636,RC,90656,CPT,4928142450,NDC,,,,inpatient,facility,0.5,UN,65.77,65.77,5.26,65.77,,,,,,,,,,,,,,65.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.19,,,percent of total billed charges,,,,,,,,,65.77,,,percent of total billed charges,,,36.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.77,,,percent of total billed charges,,,,,,,,,,,,,,,65.77,,,percent of total billed charges,,,34.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.26,,,percent of total billed charges,,,65.77,,,percent of total billed charges,,,65.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.18,,,percent of total billed charges,,
INFLU (FLUZONE TRIV) PF 0.5ML,2500003841,CDM,636,RC,90656,CPT,4928142450,NDC,,,,outpatient,facility,0.5,UN,65.77,65.77,5.26,618.77,,38.41,,,percent of total billed charges,,,19.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,65.77,,,percent of total billed charges,,,23.37,,,fee schedule,,,22.52,,,fee schedule,,,18.69,,,fee schedule,,,22.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,65.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.88,,,fee schedule,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,42.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,59.19,,,percent of total billed charges,,,18.69,,,fee schedule,,,65.77,,,percent of total billed charges,,,44.54,,,percent of total billed charges,,,19.62,,,fee schedule,,,19.62,,,fee schedule,,,,,,,,,18.69,,,fee schedule,,,18.69,,,fee schedule,,,19.62,,,fee schedule,,,50.51,,,percent of total billed charges,,,,,,,,,27.1,,,fee schedule,,,19.77,,,fee schedule,,,19.77,,,fee schedule,,,19.25,,,fee schedule,,,618.77,,,per diem,,,65.77,,,percent of total billed charges,,,18.04,,,fee schedule,,,20,,,fee schedule,,,20.02,,,fee schedule,,,34.29,,,percent of total billed charges,,,65.77,,,percent of total billed charges,,,65.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.69,,,fee schedule,,,18.69,,,fee schedule,,,49.99,,,percent of total billed charges,,,24.91,,,percent of total billed charges,,,34.06,,,percent of total billed charges,,,,,,,,,19.83,,,fee schedule,,,13.15,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,43.63,,,fee schedule,,,19.45,,,fee schedule,,,23.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.26,,,percent of total billed charges,,,65.77,,,percent of total billed charges,,,65.77,,,percent of total billed charges,,,18.69,,,fee schedule,,,18.69,,,fee schedule,,,65.77,,,percent of total billed charges,,,65.77,,,percent of total billed charges,,,18.69,,,fee schedule,,,22.35,,,fee schedule,,,20.76,,,fee schedule,,,18.69,,,fee schedule,,,19.25,,,fee schedule,,,18.26,,,fee schedule,,,24.34,,,fee schedule,,,13.49,,,fee schedule,,,16.6,,,fee schedule,,,65.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,65.77,,,percent of total billed charges,,,65.77,,,percent of total billed charges,,,35.26,,,fee schedule,,,18.69,,,fee schedule,,,19.93,,,fee schedule,,,18.69,,,fee schedule,,,18.69,,,fee schedule,,,19.07,,,fee schedule,,,32.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,19.07,,,fee schedule,,,46.18,,,percent of total billed charges,,
INFLU (FLUZONE TRIV) PF 0.5ML,2500003841,CDM,636,RC,90656,CPT,4928142450,NDC,414,EAPG,,outpatient,facility,0.5,UN,65.77,65.77,23.83,34.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.93,,,fee schedule,,,23.83,,,fee schedule,,,31.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHOTREXATE INJ 50 MG  (2ML),2500004140,CDM,636,RC,J9260,HCPCS,6170335038,NDC,,,,inpatient,facility,2,UN,23.99,23.99,1.92,23.99,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.59,,,percent of total billed charges,,,,,,,,,23.99,,,percent of total billed charges,,,13.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.85,,,percent of total billed charges,,
METHOTREXATE INJ 50 MG  (2ML),2500004140,CDM,636,RC,J9260,HCPCS,6170335038,NDC,,,,outpatient,facility,2,UN,23.99,23.99,1.92,618.77,,2.57,,,fee schedule,,,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,23.99,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,21.59,,,percent of total billed charges,,,,,,,,,23.99,,,percent of total billed charges,,,16.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.23,,,percent of total billed charges,,,9.09,,,percent of total billed charges,,,12.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,23.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.92,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,,,,,,,23.99,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.67,,,fee schedule,,,23.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,23.99,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,16.85,,,percent of total billed charges,,
METHOTREXATE INJ 50 MG  (2ML),2500004140,CDM,636,RC,J9260,HCPCS,6170335038,NDC,495,EAPG,,outpatient,facility,2,UN,23.99,23.99,20.56,30.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.14,,,fee schedule,,,20.56,,,fee schedule,,,26.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.56,,,fee schedule,,,20.56,,,fee schedule,,,20.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,20.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DARUNAVIR 800 MG TAB,2500004429,CDM,637,RC,5967656630,NDC,,,,,,inpatient,facility,800,UN,237.4,237.4,18.99,237.4,,,,,,,,,,,,,,237.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.66,,,percent of total billed charges,,,,,,,,,237.4,,,percent of total billed charges,,,131.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,216.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.4,,,percent of total billed charges,,,,,,,,,,,,,,,237.4,,,percent of total billed charges,,,123.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.99,,,percent of total billed charges,,,237.4,,,percent of total billed charges,,,237.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,237.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.7,,,percent of total billed charges,,
DARUNAVIR 800 MG TAB,2500004429,CDM,637,RC,5967656630,NDC,,,,,,outpatient,facility,800,UN,237.4,237.4,18.99,618.77,,138.64,,,percent of total billed charges,,,46.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,237.4,,,percent of total billed charges,,,209.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,209.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,209.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,237.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,86.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,213.66,,,percent of total billed charges,,,,,,,,,237.4,,,percent of total billed charges,,,160.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.32,,,percent of total billed charges,,,,,,,,,,,,,,,128.2,,,percent of total billed charges,,,128.2,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,237.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.78,,,percent of total billed charges,,,237.4,,,percent of total billed charges,,,237.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.42,,,percent of total billed charges,,,89.93,,,percent of total billed charges,,,122.95,,,percent of total billed charges,,,,,,,,,,,,,,,47.48,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,87.84,,,percent of total billed charges,,,87.84,,,percent of total billed charges,,,237.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,237.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.99,,,percent of total billed charges,,,237.4,,,percent of total billed charges,,,237.4,,,percent of total billed charges,,,,,,,,,,,,,,,237.4,,,percent of total billed charges,,,237.4,,,percent of total billed charges,,,,,,,,,237.4,,,fee schedule,,,220.83,,,percent of total billed charges,,,,,,,,,,,,,,,220.83,,,percent of total billed charges,,,220.83,,,percent of total billed charges,,,220.83,,,percent of total billed charges,,,178.05,,,percent of total billed charges,,,237.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,237.4,,,percent of total billed charges,,,237.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,166.7,,,percent of total billed charges,,
DARUNAVIR 800 MG TAB,2500004429,CDM,637,RC,5967656630,NDC,999,EAPG,,,,outpatient,facility,800,UN,237.4,237.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOFLOXACIN INJ 250 MG,2500004600,CDM,636,RC,J1956,HCPCS,527194868,NDC,,,,inpatient,facility,10,UN,13.2,13.2,1.06,13.2,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,6.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.27,,,percent of total billed charges,,
LEVOFLOXACIN INJ 250 MG,2500004600,CDM,636,RC,J1956,HCPCS,527194868,NDC,,,,outpatient,facility,10,UN,13.2,13.2,0.97,618.77,,7.71,,,percent of total billed charges,,,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.88,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.88,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,5,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,13.2,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.97,,,fee schedule,,,13.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.27,,,percent of total billed charges,,
LEVOFLOXACIN INJ 250 MG,2500004600,CDM,636,RC,J1956,HCPCS,527194868,NDC,496,EAPG,,outpatient,facility,10,UN,13.2,13.2,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOFLOXACIN INJ 500 MG,2500004602,CDM,636,RC,J1956,HCPCS,143972124,NDC,,,,inpatient,facility,100,UN,20.2,20.2,1.62,20.2,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,,,,,,,20.2,,,percent of total billed charges,,,11.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.18,,,percent of total billed charges,,
LEVOFLOXACIN INJ 500 MG,2500004602,CDM,636,RC,J1956,HCPCS,143972124,NDC,,,,outpatient,facility,100,UN,20.2,20.2,0.97,618.77,,11.8,,,percent of total billed charges,,,3.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,20.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,18.18,,,percent of total billed charges,,,,,,,,,20.2,,,percent of total billed charges,,,13.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.53,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.35,,,percent of total billed charges,,,7.65,,,percent of total billed charges,,,10.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,20.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.62,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,,,,,,,20.2,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.97,,,fee schedule,,,20.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,20.2,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,14.18,,,percent of total billed charges,,
LEVOFLOXACIN INJ 500 MG,2500004602,CDM,636,RC,J1956,HCPCS,143972124,NDC,496,EAPG,,outpatient,facility,100,UN,20.2,20.2,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUMIN 25  50 ML,2500004690,CDM,636,RC,P9047,HCPCS,6898264301,NDC,,,,inpatient,facility,50,ML,189.42,189.42,15.15,189.42,,,,,,,,,,,,,,189.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.48,,,percent of total billed charges,,,,,,,,,189.42,,,percent of total billed charges,,,104.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.42,,,percent of total billed charges,,,,,,,,,,,,,,,189.42,,,percent of total billed charges,,,98.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,189.42,,,percent of total billed charges,,,189.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,189.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.01,,,percent of total billed charges,,
ALBUMIN 25  50 ML,2500004690,CDM,636,RC,P9047,HCPCS,6898264301,NDC,,,,outpatient,facility,50,ML,189.42,189.42,15.15,618.77,,110.62,,,percent of total billed charges,,,36.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,189.42,,,percent of total billed charges,,,62.74,,,fee schedule,,,60.46,,,fee schedule,,,,,,,,,60.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,189.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,69.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,170.48,,,percent of total billed charges,,,,,,,,,189.42,,,percent of total billed charges,,,128.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.47,,,percent of total billed charges,,,,,,,,,,,,,,,45.9,,,fee schedule,,,45.9,,,fee schedule,,,,,,,,,618.77,,,per diem,,,189.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.76,,,percent of total billed charges,,,189.42,,,percent of total billed charges,,,189.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.96,,,percent of total billed charges,,,71.75,,,percent of total billed charges,,,98.1,,,percent of total billed charges,,,,,,,,,,,,,,,37.88,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,115.76,,,fee schedule,,,51.61,,,fee schedule,,,189.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,189.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.15,,,percent of total billed charges,,,189.42,,,percent of total billed charges,,,189.42,,,percent of total billed charges,,,,,,,,,,,,,,,189.42,,,percent of total billed charges,,,189.42,,,percent of total billed charges,,,,,,,,,189.42,,,fee schedule,,,55.07,,,fee schedule,,,,,,,,,,,,,,,48.43,,,fee schedule,,,64.57,,,fee schedule,,,35.8,,,fee schedule,,,55.08,,,fee schedule,,,189.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,189.42,,,percent of total billed charges,,,189.42,,,percent of total billed charges,,,53.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,133.01,,,percent of total billed charges,,
ALBUMIN 25  50 ML,2500004690,CDM,636,RC,P9047,HCPCS,6898264301,NDC,999,EAPG,,outpatient,facility,50,ML,189.42,189.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUMIN 25  100 ML,2500004692,CDM,636,RC,P9047,HCPCS,6898264302,NDC,,,,inpatient,facility,100,ML,378.84,378.84,30.31,378.84,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.96,,,percent of total billed charges,,,,,,,,,378.84,,,percent of total billed charges,,,209.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,197.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.31,,,percent of total billed charges,,,378.84,,,percent of total billed charges,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.02,,,percent of total billed charges,,
ALBUMIN 25  100 ML,2500004692,CDM,636,RC,P9047,HCPCS,6898264302,NDC,,,,outpatient,facility,100,ML,378.84,378.84,30.31,618.77,,221.24,,,percent of total billed charges,,,73.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,378.84,,,percent of total billed charges,,,62.74,,,fee schedule,,,60.46,,,fee schedule,,,,,,,,,60.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,138.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,340.96,,,percent of total billed charges,,,,,,,,,378.84,,,percent of total billed charges,,,256.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.95,,,percent of total billed charges,,,,,,,,,,,,,,,45.9,,,fee schedule,,,45.9,,,fee schedule,,,,,,,,,618.77,,,per diem,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,197.53,,,percent of total billed charges,,,378.84,,,percent of total billed charges,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.92,,,percent of total billed charges,,,143.5,,,percent of total billed charges,,,196.2,,,percent of total billed charges,,,,,,,,,,,,,,,75.77,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,115.76,,,fee schedule,,,51.61,,,fee schedule,,,378.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,378.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.31,,,percent of total billed charges,,,378.84,,,percent of total billed charges,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,378.84,,,percent of total billed charges,,,,,,,,,378.84,,,fee schedule,,,55.07,,,fee schedule,,,,,,,,,,,,,,,48.43,,,fee schedule,,,64.57,,,fee schedule,,,35.8,,,fee schedule,,,55.08,,,fee schedule,,,378.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,378.84,,,percent of total billed charges,,,378.84,,,percent of total billed charges,,,53.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,266.02,,,percent of total billed charges,,
ALBUMIN 25  100 ML,2500004692,CDM,636,RC,P9047,HCPCS,6898264302,NDC,999,EAPG,,outpatient,facility,100,ML,378.84,378.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUMIN 5   500 ML,2500004700,CDM,636,RC,P9045,HCPCS,6898262303,NDC,,,,inpatient,facility,500,ML,712.8,712.8,57.02,712.8,,,,,,,,,,,,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.52,,,percent of total billed charges,,,,,,,,,712.8,,,percent of total billed charges,,,394.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,712.8,,,percent of total billed charges,,,371.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,712.8,,,percent of total billed charges,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.53,,,percent of total billed charges,,
ALBUMIN 5   500 ML,2500004700,CDM,636,RC,P9045,HCPCS,6898262303,NDC,,,,outpatient,facility,500,ML,712.8,712.8,35.8,712.8,,416.28,,,percent of total billed charges,,,,,,,,,712.8,,,percent of total billed charges,,,62.74,,,fee schedule,,,60.46,,,fee schedule,,,,,,,,,60.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,641.52,,,percent of total billed charges,,,,,,,,,712.8,,,percent of total billed charges,,,482.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,547.43,,,percent of total billed charges,,,,,,,,,,,,,,,47.49,,,fee schedule,,,47.49,,,fee schedule,,,,,,,,,618.77,,,per diem,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,371.65,,,percent of total billed charges,,,712.8,,,percent of total billed charges,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,541.73,,,percent of total billed charges,,,270.01,,,percent of total billed charges,,,369.16,,,percent of total billed charges,,,,,,,,,,,,,,,142.56,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,115.76,,,fee schedule,,,51.61,,,fee schedule,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,712.8,,,percent of total billed charges,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,712.8,,,percent of total billed charges,,,712.8,,,percent of total billed charges,,,,,,,,,712.8,,,fee schedule,,,55.07,,,fee schedule,,,,,,,,,,,,,,,48.43,,,fee schedule,,,64.57,,,fee schedule,,,35.8,,,fee schedule,,,55.08,,,fee schedule,,,712.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,712.8,,,percent of total billed charges,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,356.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,500.53,,,percent of total billed charges,,
ALBUMIN 5   500 ML,2500004700,CDM,636,RC,P9045,HCPCS,6898262303,NDC,963,APC,,outpatient,facility,500,ML,712.8,712.8,50.96,260.88,,,,,,,,54.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.61,,,fee schedule,,,,,,,,,260.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,53.08,,,fee schedule,,,55.73,,,fee schedule,,,,,,,,,53.08,,,fee schedule,,,53.08,,,fee schedule,,,55.73,,,fee schedule,,,,,,,,,,,,,,,76.97,,,fee schedule,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,50.96,,,fee schedule,,,56.8,,,fee schedule,,,55.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,53.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,55.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,66.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,53.08,,,fee schedule,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,53.08,,,fee schedule,,,54.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,53.08,,,fee schedule,,,55.2,,,fee schedule,,,53.08,,,fee schedule,,,,,,,,,53.08,,,fee schedule,,,,,,,,,53.08,,,fee schedule,,,,,,,,
ALBUMIN 5   500 ML,2500004700,CDM,636,RC,P9045,HCPCS,6898262303,NDC,999,EAPG,,outpatient,facility,500,ML,712.8,712.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUMIN 5   250 ML,2500004703,CDM,636,RC,P9045,HCPCS,6898262302,NDC,,,,inpatient,facility,250,ML,228.69,228.69,18.3,228.69,,,,,,,,,,,,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.82,,,percent of total billed charges,,,,,,,,,228.69,,,percent of total billed charges,,,126.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,208.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,228.69,,,percent of total billed charges,,,119.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.3,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.59,,,percent of total billed charges,,
ALBUMIN 5   250 ML,2500004703,CDM,636,RC,P9045,HCPCS,6898262302,NDC,,,,outpatient,facility,250,ML,228.69,228.69,18.3,618.77,,133.55,,,percent of total billed charges,,,,,,,,,228.69,,,percent of total billed charges,,,62.74,,,fee schedule,,,60.46,,,fee schedule,,,,,,,,,60.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,205.82,,,percent of total billed charges,,,,,,,,,228.69,,,percent of total billed charges,,,154.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.63,,,percent of total billed charges,,,,,,,,,,,,,,,47.49,,,fee schedule,,,47.49,,,fee schedule,,,,,,,,,618.77,,,per diem,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.24,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.8,,,percent of total billed charges,,,86.63,,,percent of total billed charges,,,118.44,,,percent of total billed charges,,,,,,,,,,,,,,,45.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,115.76,,,fee schedule,,,51.61,,,fee schedule,,,,,,,,,,,,,,,18.3,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,228.69,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,,,,,,,228.69,,,fee schedule,,,55.07,,,fee schedule,,,,,,,,,,,,,,,48.43,,,fee schedule,,,64.57,,,fee schedule,,,35.8,,,fee schedule,,,55.08,,,fee schedule,,,228.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,228.69,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,160.59,,,percent of total billed charges,,
ALBUMIN 5   250 ML,2500004703,CDM,636,RC,P9045,HCPCS,6898262302,NDC,963,APC,,outpatient,facility,250,ML,228.69,228.69,50.96,83.7,,,,,,,,54.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.61,,,fee schedule,,,,,,,,,83.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,53.08,,,fee schedule,,,55.73,,,fee schedule,,,,,,,,,53.08,,,fee schedule,,,53.08,,,fee schedule,,,55.73,,,fee schedule,,,,,,,,,,,,,,,76.97,,,fee schedule,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,50.96,,,fee schedule,,,56.8,,,fee schedule,,,55.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,53.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,55.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,66.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,53.08,,,fee schedule,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,53.08,,,fee schedule,,,54.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,53.08,,,fee schedule,,,55.2,,,fee schedule,,,53.08,,,fee schedule,,,,,,,,,53.08,,,fee schedule,,,,,,,,,53.08,,,fee schedule,,,,,,,,
ALBUMIN 5   250 ML,2500004703,CDM,636,RC,P9045,HCPCS,6898262302,NDC,999,EAPG,,outpatient,facility,250,ML,228.69,228.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETYLCYSTEINE INH 6 GRAM,2500004846,CDM,637,RC,J7608,HCPCS,6332369030,NDC,,,,inpatient,facility,30,GR,85.83,85.83,6.87,85.83,,,,,,,,,,,,,,85.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.25,,,percent of total billed charges,,,,,,,,,85.83,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.83,,,percent of total billed charges,,,,,,,,,,,,,,,85.83,,,percent of total billed charges,,,44.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.87,,,percent of total billed charges,,,85.83,,,percent of total billed charges,,,85.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.27,,,percent of total billed charges,,
ACETYLCYSTEINE INH 6 GRAM,2500004846,CDM,637,RC,J7608,HCPCS,6332369030,NDC,,,,outpatient,facility,30,GR,85.83,85.83,5.04,618.77,,50.12,,,percent of total billed charges,,,16.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,85.83,,,percent of total billed charges,,,10.77,,,fee schedule,,,10.38,,,fee schedule,,,,,,,,,10.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,85.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,31.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,77.25,,,percent of total billed charges,,,,,,,,,85.83,,,percent of total billed charges,,,58.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.92,,,percent of total billed charges,,,,,,,,,,,,,,,6.83,,,fee schedule,,,6.83,,,fee schedule,,,,,,,,,618.77,,,per diem,,,85.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,44.75,,,percent of total billed charges,,,85.83,,,percent of total billed charges,,,85.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.23,,,percent of total billed charges,,,32.51,,,percent of total billed charges,,,44.45,,,percent of total billed charges,,,,,,,,,,,,,,,17.17,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,16.31,,,fee schedule,,,7.27,,,fee schedule,,,85.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,85.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.87,,,percent of total billed charges,,,85.83,,,percent of total billed charges,,,85.83,,,percent of total billed charges,,,,,,,,,,,,,,,85.83,,,percent of total billed charges,,,85.83,,,percent of total billed charges,,,,,,,,,7.77,,,fee schedule,,,7.76,,,fee schedule,,,,,,,,,,,,,,,6.83,,,fee schedule,,,9.1,,,fee schedule,,,5.04,,,fee schedule,,,9.45,,,fee schedule,,,85.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,85.83,,,percent of total billed charges,,,85.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,60.27,,,percent of total billed charges,,
ACETYLCYSTEINE INH 6 GRAM,2500004846,CDM,637,RC,J7608,HCPCS,6332369030,NDC,496,EAPG,,outpatient,facility,30,GR,85.83,85.83,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACYCLOVIR  SOD 500 MG INJ,2500004852,CDM,636,RC,J0133,HCPCS,5515015410,NDC,,,,inpatient,facility,10,GR,52.8,52.8,4.22,52.8,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,,,,,,,52.8,,,percent of total billed charges,,,29.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,27.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.08,,,percent of total billed charges,,
ACYCLOVIR  SOD 500 MG INJ,2500004852,CDM,636,RC,J0133,HCPCS,5515015410,NDC,,,,outpatient,facility,10,GR,52.8,52.8,0.04,618.77,,30.84,,,percent of total billed charges,,,10.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,52.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,19.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,47.52,,,percent of total billed charges,,,,,,,,,52.8,,,percent of total billed charges,,,35.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.53,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.13,,,percent of total billed charges,,,20,,,percent of total billed charges,,,27.35,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,52.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,52.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.22,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,52.8,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.04,,,fee schedule,,,52.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,37.08,,,percent of total billed charges,,
ACYCLOVIR  SOD 500 MG INJ,2500004852,CDM,636,RC,J0133,HCPCS,5515015410,NDC,999,EAPG,,outpatient,facility,10,GR,52.8,52.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AZITHROMYCIN 500 MG INJ,2500004880,CDM,636,RC,J0456,HCPCS,7043601982,NDC,,,,inpatient,facility,500,UN,57.09,57.09,4.57,57.09,,,,,,,,,,,,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.38,,,percent of total billed charges,,,,,,,,,57.09,,,percent of total billed charges,,,31.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,57.09,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.57,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.09,,,percent of total billed charges,,
AZITHROMYCIN 500 MG INJ,2500004880,CDM,636,RC,J0456,HCPCS,7043601982,NDC,,,,outpatient,facility,500,UN,57.09,57.09,2.26,618.77,,33.34,,,percent of total billed charges,,,11.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,57.09,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,20.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,51.38,,,percent of total billed charges,,,,,,,,,57.09,,,percent of total billed charges,,,38.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.77,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.39,,,percent of total billed charges,,,21.63,,,percent of total billed charges,,,29.57,,,percent of total billed charges,,,,,,,,,,,,,,,11.42,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,57.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,57.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.57,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,57.09,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,,,,,,,57.09,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.26,,,fee schedule,,,57.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,57.09,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,40.09,,,percent of total billed charges,,
AZITHROMYCIN 500 MG INJ,2500004880,CDM,636,RC,J0456,HCPCS,7043601982,NDC,496,EAPG,,outpatient,facility,500,UN,57.09,57.09,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AZTREONAM 1000 MG INJ,2500004892,CDM,636,RC,J0457,HCPCS,6332340120,NDC,,,,inpatient,facility,1,UN,119.06,119.06,9.52,119.06,,,,,,,,,,,,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.15,,,percent of total billed charges,,,,,,,,,119.06,,,percent of total billed charges,,,65.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,,119.06,,,percent of total billed charges,,,62.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.52,,,percent of total billed charges,,,119.06,,,percent of total billed charges,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.6,,,percent of total billed charges,,
AZTREONAM 1000 MG INJ,2500004892,CDM,636,RC,J0457,HCPCS,6332340120,NDC,,,,outpatient,facility,1,UN,119.06,119.06,1.97,618.77,,69.53,,,percent of total billed charges,,,23.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,119.06,,,percent of total billed charges,,,2.52,,,fee schedule,,,2.43,,,fee schedule,,,,,,,,,2.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,43.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,107.15,,,percent of total billed charges,,,,,,,,,119.06,,,percent of total billed charges,,,80.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.08,,,percent of total billed charges,,,119.06,,,percent of total billed charges,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.49,,,percent of total billed charges,,,45.1,,,percent of total billed charges,,,61.66,,,percent of total billed charges,,,,,,,,,,,,,,,23.81,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,119.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,119.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.52,,,percent of total billed charges,,,119.06,,,percent of total billed charges,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,,119.06,,,percent of total billed charges,,,119.06,,,percent of total billed charges,,,,,,,,,119.06,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.21,,,fee schedule,,,119.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,119.06,,,percent of total billed charges,,,119.06,,,percent of total billed charges,,,1.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,83.6,,,percent of total billed charges,,
AZTREONAM 1000 MG INJ,2500004892,CDM,636,RC,J0457,HCPCS,6332340120,NDC,435,EAPG,,outpatient,facility,1,UN,119.06,119.06,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AZTREONAM 2000 MG INJ,2500004894,CDM,636,RC,J0457,HCPCS,6332340220,NDC,,,,inpatient,facility,2,UN,241.92,241.92,19.35,241.92,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.73,,,percent of total billed charges,,,,,,,,,241.92,,,percent of total billed charges,,,133.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,126.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.35,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.88,,,percent of total billed charges,,
AZTREONAM 2000 MG INJ,2500004894,CDM,636,RC,J0457,HCPCS,6332340220,NDC,,,,outpatient,facility,2,UN,241.92,241.92,1.97,618.77,,141.28,,,percent of total billed charges,,,47.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,241.92,,,percent of total billed charges,,,2.52,,,fee schedule,,,2.43,,,fee schedule,,,,,,,,,2.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,88.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,217.73,,,percent of total billed charges,,,,,,,,,241.92,,,percent of total billed charges,,,163.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.14,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.86,,,percent of total billed charges,,,91.64,,,percent of total billed charges,,,125.29,,,percent of total billed charges,,,,,,,,,,,,,,,48.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,241.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,241.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.35,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,241.92,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.21,,,fee schedule,,,241.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,1.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,169.88,,,percent of total billed charges,,
AZTREONAM 2000 MG INJ,2500004894,CDM,636,RC,J0457,HCPCS,6332340220,NDC,435,EAPG,,outpatient,facility,2,UN,241.92,241.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CIPROFLOXACIN INJ 200MG,2500004950,CDM,636,RC,J0744,HCPCS,3600000824,NDC,,,,inpatient,facility,100,UN,9.9,9.9,0.79,9.9,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,5.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.95,,,percent of total billed charges,,
CIPROFLOXACIN INJ 200MG,2500004950,CDM,636,RC,J0744,HCPCS,3600000824,NDC,,,,outpatient,facility,100,UN,9.9,9.9,0.79,618.77,,5.78,,,percent of total billed charges,,,1.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.9,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.91,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.16,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.52,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,9.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,9.9,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.91,,,fee schedule,,,9.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.95,,,percent of total billed charges,,
CIPROFLOXACIN INJ 200MG,2500004950,CDM,636,RC,J0744,HCPCS,3600000824,NDC,999,EAPG,,outpatient,facility,100,UN,9.9,9.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CIPROFLOXACIN INJ 400 MG IVBAG,2500004954,CDM,636,RC,J0744,HCPCS,3600000924,NDC,,,,inpatient,facility,200,UN,11.55,11.55,0.92,11.55,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.4,,,percent of total billed charges,,,,,,,,,11.55,,,percent of total billed charges,,,6.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.11,,,percent of total billed charges,,
CIPROFLOXACIN INJ 400 MG IVBAG,2500004954,CDM,636,RC,J0744,HCPCS,3600000924,NDC,,,,outpatient,facility,200,UN,11.55,11.55,0.92,618.77,,6.75,,,percent of total billed charges,,,2.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.4,,,percent of total billed charges,,,,,,,,,11.55,,,percent of total billed charges,,,7.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,5.98,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,11.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,11.55,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.91,,,fee schedule,,,11.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.11,,,percent of total billed charges,,
CIPROFLOXACIN INJ 400 MG IVBAG,2500004954,CDM,636,RC,J0744,HCPCS,3600000924,NDC,999,EAPG,,outpatient,facility,200,UN,11.55,11.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLINDAMYCIN PHOS INJ 300 MG,2500004960,CDM,636,RC,J0736,HCPCS,781328809,NDC,,,,inpatient,facility,100,UN,8.71,8.71,0.7,8.71,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.84,,,percent of total billed charges,,,,,,,,,8.71,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,4.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,
CLINDAMYCIN PHOS INJ 300 MG,2500004960,CDM,636,RC,J0736,HCPCS,781328809,NDC,,,,outpatient,facility,100,UN,8.71,8.71,0.7,618.77,,5.09,,,percent of total billed charges,,,1.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.71,,,percent of total billed charges,,,2.82,,,fee schedule,,,2.72,,,fee schedule,,,,,,,,,2.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.84,,,percent of total billed charges,,,,,,,,,8.71,,,percent of total billed charges,,,5.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.54,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.62,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,4.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,8.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.7,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,,,,,,,8.71,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.49,,,fee schedule,,,8.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.71,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,2.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.12,,,percent of total billed charges,,
CLINDAMYCIN PHOS INJ 300 MG,2500004960,CDM,636,RC,J0736,HCPCS,781328809,NDC,435,EAPG,,outpatient,facility,100,UN,8.71,8.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLINDAMYCIN PHOS INJ 600 MG,2500004962,CDM,636,RC,J0736,HCPCS,781328909,NDC,,,,inpatient,facility,100,UN,48.97,48.97,3.92,48.97,,,,,,,,,,,,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.07,,,percent of total billed charges,,,,,,,,,48.97,,,percent of total billed charges,,,27.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,,48.97,,,percent of total billed charges,,,25.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,48.97,,,percent of total billed charges,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.39,,,percent of total billed charges,,
CLINDAMYCIN PHOS INJ 600 MG,2500004962,CDM,636,RC,J0736,HCPCS,781328909,NDC,,,,outpatient,facility,100,UN,48.97,48.97,2.47,618.77,,28.6,,,percent of total billed charges,,,9.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,48.97,,,percent of total billed charges,,,2.82,,,fee schedule,,,2.72,,,fee schedule,,,,,,,,,2.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,44.07,,,percent of total billed charges,,,,,,,,,48.97,,,percent of total billed charges,,,33.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.53,,,percent of total billed charges,,,48.97,,,percent of total billed charges,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.22,,,percent of total billed charges,,,18.55,,,percent of total billed charges,,,25.36,,,percent of total billed charges,,,,,,,,,,,,,,,9.79,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,48.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,48.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.92,,,percent of total billed charges,,,48.97,,,percent of total billed charges,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,,48.97,,,percent of total billed charges,,,48.97,,,percent of total billed charges,,,,,,,,,48.97,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.49,,,fee schedule,,,48.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,48.97,,,percent of total billed charges,,,48.97,,,percent of total billed charges,,,2.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,34.39,,,percent of total billed charges,,
CLINDAMYCIN PHOS INJ 600 MG,2500004962,CDM,636,RC,J0736,HCPCS,781328909,NDC,435,EAPG,,outpatient,facility,100,UN,48.97,48.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLINDAMYCIN PHOS INJ 900 MG,2500004964,CDM,636,RC,J0736,HCPCS,781329009,NDC,,,,inpatient,facility,50,UN,47.19,47.19,3.78,47.19,,,,,,,,,,,,,,47.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.47,,,percent of total billed charges,,,,,,,,,47.19,,,percent of total billed charges,,,26.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.19,,,percent of total billed charges,,,,,,,,,,,,,,,47.19,,,percent of total billed charges,,,24.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.78,,,percent of total billed charges,,,47.19,,,percent of total billed charges,,,47.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.14,,,percent of total billed charges,,
CLINDAMYCIN PHOS INJ 900 MG,2500004964,CDM,636,RC,J0736,HCPCS,781329009,NDC,,,,outpatient,facility,50,UN,47.19,47.19,2.47,618.77,,27.56,,,percent of total billed charges,,,9.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,47.19,,,percent of total billed charges,,,2.82,,,fee schedule,,,2.72,,,fee schedule,,,,,,,,,2.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,47.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,42.47,,,percent of total billed charges,,,,,,,,,47.19,,,percent of total billed charges,,,31.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,47.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.6,,,percent of total billed charges,,,47.19,,,percent of total billed charges,,,47.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.86,,,percent of total billed charges,,,17.88,,,percent of total billed charges,,,24.44,,,percent of total billed charges,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,47.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,47.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.78,,,percent of total billed charges,,,47.19,,,percent of total billed charges,,,47.19,,,percent of total billed charges,,,,,,,,,,,,,,,47.19,,,percent of total billed charges,,,47.19,,,percent of total billed charges,,,,,,,,,47.19,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.49,,,fee schedule,,,47.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,47.19,,,percent of total billed charges,,,47.19,,,percent of total billed charges,,,2.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,33.14,,,percent of total billed charges,,
CLINDAMYCIN PHOS INJ 900 MG,2500004964,CDM,636,RC,J0736,HCPCS,781329009,NDC,435,EAPG,,outpatient,facility,50,UN,47.19,47.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FAMOTIDINE INJ 20MG,2500005010,CDM,250,RC,J3490,HCPCS,6332373912,NDC,,,,inpatient,facility,2,ML,2.97,2.97,0.24,2.97,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.09,,,percent of total billed charges,,
FAMOTIDINE INJ 20MG,2500005010,CDM,250,RC,J3490,HCPCS,6332373912,NDC,,,,outpatient,facility,2,ML,2.97,2.97,0.24,618.77,,1.73,,,percent of total billed charges,,,0.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.97,,,percent of total billed charges,,,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.67,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.23,,,percent of total billed charges,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.09,,,percent of total billed charges,,
FAMOTIDINE INJ 20MG,2500005010,CDM,250,RC,J3490,HCPCS,6332373912,NDC,435,EAPG,,outpatient,facility,2,ML,2.97,2.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUCONAZOLE INJ UPTO 200MG,2500005020,CDM,636,RC,J1450,HCPCS,2502111382,NDC,,,,inpatient,facility,1,UN,29.7,29.7,2.38,29.7,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.73,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,16.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,15.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.86,,,percent of total billed charges,,
FLUCONAZOLE INJ UPTO 200MG,2500005020,CDM,636,RC,J1450,HCPCS,2502111382,NDC,,,,outpatient,facility,1,UN,29.7,29.7,2.38,618.77,,17.34,,,percent of total billed charges,,,5.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,29.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26.73,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,20.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.49,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,15.38,,,percent of total billed charges,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,29.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.38,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,29.7,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.54,,,fee schedule,,,29.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.86,,,percent of total billed charges,,
FLUCONAZOLE INJ UPTO 200MG,2500005020,CDM,636,RC,J1450,HCPCS,2502111382,NDC,999,EAPG,,outpatient,facility,1,UN,29.7,29.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUCONAZOLE INJ 400MG,2500005023,CDM,636,RC,J1450,HCPCS,2502118487,NDC,,,,inpatient,facility,200,UN,46.2,46.2,3.7,46.2,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.58,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,25.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,24.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.44,,,percent of total billed charges,,
FLUCONAZOLE INJ 400MG,2500005023,CDM,636,RC,J1450,HCPCS,2502118487,NDC,,,,outpatient,facility,200,UN,46.2,46.2,2.54,618.77,,26.98,,,percent of total billed charges,,,9.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,46.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,41.58,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,31.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.09,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.11,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,46.2,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.54,,,fee schedule,,,46.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,32.44,,,percent of total billed charges,,
FLUCONAZOLE INJ 400MG,2500005023,CDM,636,RC,J1450,HCPCS,2502118487,NDC,999,EAPG,,outpatient,facility,200,UN,46.2,46.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCTREOTIDE ACET IV SC 100 MCG,2500005107,CDM,636,RC,J2354,HCPCS,6745724501,NDC,,,,inpatient,facility,1,UN,31.28,31.28,2.5,31.28,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.15,,,percent of total billed charges,,,,,,,,,31.28,,,percent of total billed charges,,,17.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,16.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.96,,,percent of total billed charges,,
OCTREOTIDE ACET IV SC 100 MCG,2500005107,CDM,636,RC,J2354,HCPCS,6745724501,NDC,,,,outpatient,facility,1,UN,31.28,31.28,0.94,618.77,,18.27,,,percent of total billed charges,,,6.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,31.28,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,28.15,,,percent of total billed charges,,,,,,,,,31.28,,,percent of total billed charges,,,21.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.31,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.77,,,percent of total billed charges,,,11.85,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,31.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.5,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,31.28,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.94,,,fee schedule,,,31.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,21.96,,,percent of total billed charges,,
OCTREOTIDE ACET IV SC 100 MCG,2500005107,CDM,636,RC,J2354,HCPCS,6745724501,NDC,496,EAPG,,outpatient,facility,1,UN,31.28,31.28,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCTREOTIDE ACET IV SC 500 MCG,2500005108,CDM,636,RC,J2354,HCPCS,6745724501,NDC,,,,inpatient,facility,50,ML,163.98,163.98,13.12,163.98,,,,,,,,,,,,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.58,,,percent of total billed charges,,,,,,,,,163.98,,,percent of total billed charges,,,90.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,163.98,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.12,,,percent of total billed charges,,,163.98,,,percent of total billed charges,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,
OCTREOTIDE ACET IV SC 500 MCG,2500005108,CDM,636,RC,J2354,HCPCS,6745724501,NDC,,,,outpatient,facility,50,ML,163.98,163.98,0.94,618.77,,95.76,,,percent of total billed charges,,,31.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,163.98,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,60.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,147.58,,,percent of total billed charges,,,,,,,,,163.98,,,percent of total billed charges,,,111.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.5,,,percent of total billed charges,,,163.98,,,percent of total billed charges,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.62,,,percent of total billed charges,,,62.12,,,percent of total billed charges,,,84.93,,,percent of total billed charges,,,,,,,,,,,,,,,32.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,163.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,163.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.12,,,percent of total billed charges,,,163.98,,,percent of total billed charges,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,163.98,,,percent of total billed charges,,,163.98,,,percent of total billed charges,,,,,,,,,163.98,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.94,,,fee schedule,,,163.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,163.98,,,percent of total billed charges,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,115.15,,,percent of total billed charges,,
OCTREOTIDE ACET IV SC 500 MCG,2500005108,CDM,636,RC,J2354,HCPCS,6745724501,NDC,496,EAPG,,outpatient,facility,50,ML,163.98,163.98,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIPERCILLIN TAZOBACT 3.375 INJ,2500005144,CDM,636,RC,J2543,HCPCS,6050561574,NDC,,,,inpatient,facility,3.375,UN,56.69,56.69,4.54,56.69,,,,,,,,,,,,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,56.69,,,percent of total billed charges,,,31.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,56.69,,,percent of total billed charges,,,29.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.54,,,percent of total billed charges,,,56.69,,,percent of total billed charges,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.81,,,percent of total billed charges,,
PIPERCILLIN TAZOBACT 3.375 INJ,2500005144,CDM,636,RC,J2543,HCPCS,6050561574,NDC,,,,outpatient,facility,3.375,UN,56.69,56.69,1.22,618.77,,33.11,,,percent of total billed charges,,,11.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,56.69,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,20.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,51.02,,,percent of total billed charges,,,,,,,,,56.69,,,percent of total billed charges,,,38.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.56,,,percent of total billed charges,,,56.69,,,percent of total billed charges,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.08,,,percent of total billed charges,,,21.47,,,percent of total billed charges,,,29.36,,,percent of total billed charges,,,,,,,,,,,,,,,11.34,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,56.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,56.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.54,,,percent of total billed charges,,,56.69,,,percent of total billed charges,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,56.69,,,percent of total billed charges,,,56.69,,,percent of total billed charges,,,,,,,,,56.69,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.22,,,fee schedule,,,56.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,56.69,,,percent of total billed charges,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,39.81,,,percent of total billed charges,,
PIPERCILLIN TAZOBACT 3.375 INJ,2500005144,CDM,636,RC,J2543,HCPCS,6050561574,NDC,496,EAPG,,outpatient,facility,3.375,UN,56.69,56.69,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIPERCILLIN TAZOBACT 4.5 INJ,2500005146,CDM,636,RC,J2543,HCPCS,6050561594,NDC,,,,inpatient,facility,4.5,UN,71.78,71.78,5.74,71.78,,,,,,,,,,,,,,71.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.6,,,percent of total billed charges,,,,,,,,,71.78,,,percent of total billed charges,,,39.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.78,,,percent of total billed charges,,,,,,,,,,,,,,,71.78,,,percent of total billed charges,,,37.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,71.78,,,percent of total billed charges,,,71.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.4,,,percent of total billed charges,,
PIPERCILLIN TAZOBACT 4.5 INJ,2500005146,CDM,636,RC,J2543,HCPCS,6050561594,NDC,,,,outpatient,facility,4.5,UN,71.78,71.78,1.22,618.77,,41.92,,,percent of total billed charges,,,14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,71.78,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,71.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,26.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,64.6,,,percent of total billed charges,,,,,,,,,71.78,,,percent of total billed charges,,,48.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,71.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.43,,,percent of total billed charges,,,71.78,,,percent of total billed charges,,,71.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.55,,,percent of total billed charges,,,27.19,,,percent of total billed charges,,,37.17,,,percent of total billed charges,,,,,,,,,,,,,,,14.36,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,71.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,71.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.74,,,percent of total billed charges,,,71.78,,,percent of total billed charges,,,71.78,,,percent of total billed charges,,,,,,,,,,,,,,,71.78,,,percent of total billed charges,,,71.78,,,percent of total billed charges,,,,,,,,,71.78,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.22,,,fee schedule,,,71.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,71.78,,,percent of total billed charges,,,71.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,50.4,,,percent of total billed charges,,
PIPERCILLIN TAZOBACT 4.5 INJ,2500005146,CDM,636,RC,J2543,HCPCS,6050561594,NDC,496,EAPG,,outpatient,facility,4.5,UN,71.78,71.78,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SILDENAFIL CITRATE 20 MG TAB,2500005185,CDM,637,RC,S0090,HCPCS,904667106,NDC,,,,inpatient,facility,20,UN,2.77,2.77,0.22,2.77,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,
SILDENAFIL CITRATE 20 MG TAB,2500005185,CDM,637,RC,S0090,HCPCS,904667106,NDC,,,,outpatient,facility,20,UN,2.77,2.77,0.22,618.77,,1.62,,,percent of total billed charges,,,0.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,0.35,,,fee schedule,,,0.34,,,fee schedule,,,,,,,,,0.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.49,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.77,,,fee schedule,,,2.77,,,fee schedule,,,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,2.77,,,fee schedule,,,2.77,,,fee schedule,,,,,,,,,,,,,,,2.77,,,fee schedule,,,2.77,,,fee schedule,,,2.77,,,fee schedule,,,2.77,,,fee schedule,,,2.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.95,,,percent of total billed charges,,
SILDENAFIL CITRATE 20 MG TAB,2500005185,CDM,637,RC,S0090,HCPCS,904667106,NDC,999,EAPG,,outpatient,facility,20,UN,2.77,2.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD FERRIC GLUCON  62.5 MG INJ,2500005190,CDM,636,RC,J2916,HCPCS,143957010,NDC,,,,inpatient,facility,5,ML,104.94,104.94,8.4,104.94,,,,,,,,,,,,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.45,,,percent of total billed charges,,,,,,,,,104.94,,,percent of total billed charges,,,58.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,104.94,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.4,,,percent of total billed charges,,,104.94,,,percent of total billed charges,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.69,,,percent of total billed charges,,
SOD FERRIC GLUCON  62.5 MG INJ,2500005190,CDM,636,RC,J2916,HCPCS,143957010,NDC,,,,outpatient,facility,5,ML,104.94,104.94,2.22,618.77,,61.28,,,percent of total billed charges,,,20.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,104.94,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,38.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,94.45,,,percent of total billed charges,,,,,,,,,104.94,,,percent of total billed charges,,,71.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.72,,,percent of total billed charges,,,104.94,,,percent of total billed charges,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.75,,,percent of total billed charges,,,39.75,,,percent of total billed charges,,,54.35,,,percent of total billed charges,,,,,,,,,,,,,,,20.99,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,104.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,104.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.4,,,percent of total billed charges,,,104.94,,,percent of total billed charges,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,104.94,,,percent of total billed charges,,,104.94,,,percent of total billed charges,,,,,,,,,104.94,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.22,,,fee schedule,,,104.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,104.94,,,percent of total billed charges,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,73.69,,,percent of total billed charges,,
SOD FERRIC GLUCON  62.5 MG INJ,2500005190,CDM,636,RC,J2916,HCPCS,143957010,NDC,435,EAPG,,outpatient,facility,5,ML,104.94,104.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIMETHOPRIM/SULFAMET INJ 10ML,2500005230,CDM,250,RC,J3490,HCPCS,703951491,NDC,,,,inpatient,facility,10,UN,30.65,30.65,2.45,30.65,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,,,,,,,30.65,,,percent of total billed charges,,,16.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,15.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,30.65,,,percent of total billed charges,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.52,,,percent of total billed charges,,
TRIMETHOPRIM/SULFAMET INJ 10ML,2500005230,CDM,250,RC,J3490,HCPCS,703951491,NDC,,,,outpatient,facility,10,UN,30.65,30.65,1.2,618.77,,17.9,,,percent of total billed charges,,,5.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,30.65,,,percent of total billed charges,,,26.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,26.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,26.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,27.59,,,percent of total billed charges,,,,,,,,,30.65,,,percent of total billed charges,,,20.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.54,,,percent of total billed charges,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,30.65,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.98,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.29,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,15.87,,,percent of total billed charges,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,30.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.45,,,percent of total billed charges,,,30.65,,,percent of total billed charges,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,30.65,,,percent of total billed charges,,,,,,,,,30.65,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,22.99,,,percent of total billed charges,,,30.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,30.65,,,percent of total billed charges,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,21.52,,,percent of total billed charges,,
TRIMETHOPRIM/SULFAMET INJ 10ML,2500005230,CDM,250,RC,J3490,HCPCS,703951491,NDC,435,EAPG,,outpatient,facility,10,UN,30.65,30.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TOBRAMYCIN INH 300MG,2500005270,CDM,637,RC,J7682,HCPCS,6516291446,NDC,,,,inpatient,facility,5,UN,466.49,466.49,37.32,466.49,,,,,,,,,,,,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.84,,,percent of total billed charges,,,,,,,,,466.49,,,percent of total billed charges,,,258.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,466.49,,,percent of total billed charges,,,243.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.32,,,percent of total billed charges,,,466.49,,,percent of total billed charges,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,327.57,,,percent of total billed charges,,
TOBRAMYCIN INH 300MG,2500005270,CDM,637,RC,J7682,HCPCS,6516291446,NDC,,,,outpatient,facility,5,UN,466.49,466.49,15.87,618.77,,272.43,,,percent of total billed charges,,,90.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,466.49,,,percent of total billed charges,,,20.14,,,fee schedule,,,19.41,,,fee schedule,,,,,,,,,19.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,170.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,419.84,,,percent of total billed charges,,,,,,,,,466.49,,,percent of total billed charges,,,315.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.26,,,percent of total billed charges,,,,,,,,,,,,,,,21.79,,,fee schedule,,,21.79,,,fee schedule,,,,,,,,,618.77,,,per diem,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,243.23,,,percent of total billed charges,,,466.49,,,percent of total billed charges,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.53,,,percent of total billed charges,,,176.71,,,percent of total billed charges,,,241.6,,,percent of total billed charges,,,,,,,,,,,,,,,93.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,51.31,,,fee schedule,,,22.88,,,fee schedule,,,466.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,466.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,37.32,,,percent of total billed charges,,,466.49,,,percent of total billed charges,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,466.49,,,percent of total billed charges,,,466.49,,,percent of total billed charges,,,,,,,,,15.95,,,fee schedule,,,24.41,,,fee schedule,,,,,,,,,,,,,,,21.47,,,fee schedule,,,28.62,,,fee schedule,,,15.87,,,fee schedule,,,17.68,,,fee schedule,,,466.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,466.49,,,percent of total billed charges,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,327.57,,,percent of total billed charges,,
TOBRAMYCIN INH 300MG,2500005270,CDM,637,RC,J7682,HCPCS,6516291446,NDC,435,EAPG,,outpatient,facility,5,UN,466.49,466.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PERPHENAZINE 4 MG ORAL,2500005390,CDM,636,RC,Q0175,HCPCS,904660061,NDC,,,,inpatient,facility,4,UN,4.62,4.62,0.37,4.62,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,4.62,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.24,,,percent of total billed charges,,
PERPHENAZINE 4 MG ORAL,2500005390,CDM,636,RC,Q0175,HCPCS,904660061,NDC,,,,outpatient,facility,4,UN,4.62,4.62,0.37,618.77,,2.7,,,percent of total billed charges,,,0.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.62,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.16,,,percent of total billed charges,,,,,,,,,4.62,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,4.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,4.62,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,4.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.24,,,percent of total billed charges,,
PERPHENAZINE 4 MG ORAL,2500005390,CDM,636,RC,Q0175,HCPCS,904660061,NDC,999,EAPG,,outpatient,facility,4,UN,4.62,4.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PERPHENAZINE 2 MG TAB,2500005391,CDM,637,RC,Q0175,HCPCS,5253616201,NDC,,,,inpatient,facility,2,UN,5.78,5.78,0.46,5.78,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.2,,,percent of total billed charges,,,,,,,,,5.78,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,
PERPHENAZINE 2 MG TAB,2500005391,CDM,637,RC,Q0175,HCPCS,5253616201,NDC,,,,outpatient,facility,2,UN,5.78,5.78,0.46,618.77,,3.38,,,percent of total billed charges,,,1.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.78,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.2,,,percent of total billed charges,,,,,,,,,5.78,,,percent of total billed charges,,,3.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.39,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,5.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,5.78,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,5.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.06,,,percent of total billed charges,,
PERPHENAZINE 2 MG TAB,2500005391,CDM,637,RC,Q0175,HCPCS,5253616201,NDC,999,EAPG,,outpatient,facility,2,UN,5.78,5.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FOMEPIZOLE 1500 MG INJ,2500005432,CDM,636,RC,J1451,HCPCS,517071001,NDC,,,,inpatient,facility,1.5,ML,5714.31,5714.31,457.14,5714.31,,,,,,,,,,,,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5142.88,,,percent of total billed charges,,,,,,,,,5714.31,,,percent of total billed charges,,,3163.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5213.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,5714.31,,,percent of total billed charges,,,2979.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1142.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,457.14,,,percent of total billed charges,,,5714.31,,,percent of total billed charges,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4012.59,,,percent of total billed charges,,
FOMEPIZOLE 1500 MG INJ,2500005432,CDM,636,RC,J1451,HCPCS,517071001,NDC,,,,outpatient,facility,1.5,ML,5714.31,5714.31,4.79,5714.31,,3337.16,,,percent of total billed charges,,,,,,,,,5714.31,,,percent of total billed charges,,,17.02,,,fee schedule,,,16.4,,,fee schedule,,,,,,,,,16.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5142.88,,,percent of total billed charges,,,,,,,,,5714.31,,,percent of total billed charges,,,3869.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4388.59,,,percent of total billed charges,,,,,,,,,,,,,,,15.3,,,fee schedule,,,15.3,,,fee schedule,,,,,,,,,618.77,,,per diem,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2979.44,,,percent of total billed charges,,,5714.31,,,percent of total billed charges,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4342.88,,,percent of total billed charges,,,2164.58,,,percent of total billed charges,,,2959.44,,,percent of total billed charges,,,,,,,,,,,,,,,1142.86,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,15.49,,,fee schedule,,,6.91,,,fee schedule,,,,,,,,,,,,,,,457.14,,,percent of total billed charges,,,5714.31,,,percent of total billed charges,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,5714.31,,,percent of total billed charges,,,5714.31,,,percent of total billed charges,,,,,,,,,5714.31,,,fee schedule,,,7.37,,,fee schedule,,,,,,,,,,,,,,,6.48,,,fee schedule,,,8.64,,,fee schedule,,,4.79,,,fee schedule,,,8.94,,,fee schedule,,,5714.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5714.31,,,percent of total billed charges,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2857.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4012.59,,,percent of total billed charges,,
FOMEPIZOLE 1500 MG INJ,2500005432,CDM,636,RC,J1451,HCPCS,517071001,NDC,1689,APC,,outpatient,facility,1.5,ML,5714.31,5714.31,5.91,2091.44,,,,,,,,6.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.22,,,fee schedule,,,,,,,,,2091.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,6.16,,,fee schedule,,,,,,,,,,,,,,,6.16,,,fee schedule,,,6.47,,,fee schedule,,,,,,,,,6.16,,,fee schedule,,,6.16,,,fee schedule,,,6.47,,,fee schedule,,,,,,,,,,,,,,,8.93,,,fee schedule,,,,,,,,,,,,,,,6.16,,,fee schedule,,,,,,,,,,,,,,,5.91,,,fee schedule,,,6.59,,,fee schedule,,,6.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.16,,,fee schedule,,,6.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.16,,,fee schedule,,,6.16,,,fee schedule,,,,,,,,,,,,,,,6.16,,,fee schedule,,,,,,,,,,,,,,,6.16,,,fee schedule,,,6.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.44,,,fee schedule,,,6.16,,,fee schedule,,,6.41,,,fee schedule,,,6.16,,,fee schedule,,,,,,,,,6.16,,,fee schedule,,,,,,,,,6.16,,,fee schedule,,,,,,,,
FOMEPIZOLE 1500 MG INJ,2500005432,CDM,636,RC,J1451,HCPCS,517071001,NDC,999,EAPG,,outpatient,facility,1.5,ML,5714.31,5714.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FOSPHENYTOIN INJ 50 MG (33 PE),2500005440,CDM,636,RC,Q2009,HCPCS,641613625,NDC,,,,inpatient,facility,2,UN,48.84,48.84,3.91,48.84,,,,,,,,,,,,,,48.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.96,,,percent of total billed charges,,,,,,,,,48.84,,,percent of total billed charges,,,27.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.84,,,percent of total billed charges,,,,,,,,,,,,,,,48.84,,,percent of total billed charges,,,25.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.91,,,percent of total billed charges,,,48.84,,,percent of total billed charges,,,48.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.3,,,percent of total billed charges,,
FOSPHENYTOIN INJ 50 MG (33 PE),2500005440,CDM,636,RC,Q2009,HCPCS,641613625,NDC,,,,outpatient,facility,2,UN,48.84,48.84,3.2,618.77,,28.52,,,percent of total billed charges,,,9.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,48.84,,,percent of total billed charges,,,3.37,,,fee schedule,,,3.25,,,fee schedule,,,,,,,,,3.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,48.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,43.96,,,percent of total billed charges,,,,,,,,,48.84,,,percent of total billed charges,,,33.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,48.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.47,,,percent of total billed charges,,,48.84,,,percent of total billed charges,,,48.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.12,,,percent of total billed charges,,,18.5,,,percent of total billed charges,,,25.29,,,percent of total billed charges,,,,,,,,,,,,,,,9.77,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,11.26,,,fee schedule,,,5.02,,,fee schedule,,,48.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,48.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.91,,,percent of total billed charges,,,48.84,,,percent of total billed charges,,,48.84,,,percent of total billed charges,,,,,,,,,,,,,,,48.84,,,percent of total billed charges,,,48.84,,,percent of total billed charges,,,,,,,,,48.84,,,fee schedule,,,5.36,,,fee schedule,,,,,,,,,,,,,,,4.71,,,fee schedule,,,6.28,,,fee schedule,,,3.48,,,fee schedule,,,3.41,,,fee schedule,,,48.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,48.84,,,percent of total billed charges,,,48.84,,,percent of total billed charges,,,3.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,34.3,,,percent of total billed charges,,
FOSPHENYTOIN INJ 50 MG (33 PE),2500005440,CDM,636,RC,Q2009,HCPCS,641613625,NDC,435,EAPG,,outpatient,facility,2,UN,48.84,48.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FOSPHENYTOIN INJ 500MG (333PE),2500005446,CDM,636,RC,Q2009,HCPCS,6332340310,NDC,,,,inpatient,facility,10,UN,74.25,74.25,5.94,74.25,,,,,,,,,,,,,,74.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.83,,,percent of total billed charges,,,,,,,,,74.25,,,percent of total billed charges,,,41.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.25,,,percent of total billed charges,,,,,,,,,,,,,,,74.25,,,percent of total billed charges,,,38.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.14,,,percent of total billed charges,,
FOSPHENYTOIN INJ 500MG (333PE),2500005446,CDM,636,RC,Q2009,HCPCS,6332340310,NDC,,,,outpatient,facility,10,UN,74.25,74.25,3.2,618.77,,43.36,,,percent of total billed charges,,,14.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,74.25,,,percent of total billed charges,,,3.37,,,fee schedule,,,3.25,,,fee schedule,,,,,,,,,3.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,74.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,27.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,66.83,,,percent of total billed charges,,,,,,,,,74.25,,,percent of total billed charges,,,50.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,74.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.71,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.43,,,percent of total billed charges,,,28.13,,,percent of total billed charges,,,38.45,,,percent of total billed charges,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,11.26,,,fee schedule,,,5.02,,,fee schedule,,,74.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,74.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.94,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,,,,,,,,,,,,,,74.25,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,,,,,,,,74.25,,,fee schedule,,,5.36,,,fee schedule,,,,,,,,,,,,,,,4.71,,,fee schedule,,,6.28,,,fee schedule,,,3.48,,,fee schedule,,,3.41,,,fee schedule,,,74.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,74.25,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,,3.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,52.14,,,percent of total billed charges,,
FOSPHENYTOIN INJ 500MG (333PE),2500005446,CDM,636,RC,Q2009,HCPCS,6332340310,NDC,435,EAPG,,outpatient,facility,10,UN,74.25,74.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TENECTEPLACE PER 50 MG INJ,2500005770,CDM,636,RC,J3101,HCPCS,5024212047,NDC,,,,inpatient,facility,10,ML,25831.08,25831.08,2066.49,25831.08,,,,,,,,,,,,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23247.97,,,percent of total billed charges,,,,,,,,,25831.08,,,percent of total billed charges,,,14300.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23568.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,25831.08,,,percent of total billed charges,,,13468.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5166.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2066.49,,,percent of total billed charges,,,25831.08,,,percent of total billed charges,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18138.58,,,percent of total billed charges,,
TENECTEPLACE PER 50 MG INJ,2500005770,CDM,636,RC,J3101,HCPCS,5024212047,NDC,,,,outpatient,facility,10,ML,25831.08,25831.08,98.19,25831.08,,15085.35,,,percent of total billed charges,,,,,,,,,25831.08,,,percent of total billed charges,,,186.13,,,fee schedule,,,179.36,,,fee schedule,,,,,,,,,179.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,23247.97,,,percent of total billed charges,,,,,,,,,25831.08,,,percent of total billed charges,,,17492.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19838.27,,,percent of total billed charges,,,,,,,,,,,,,,,153.11,,,fee schedule,,,153.11,,,fee schedule,,,,,,,,,618.77,,,per diem,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13468.33,,,percent of total billed charges,,,25831.08,,,percent of total billed charges,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19631.62,,,percent of total billed charges,,,9784.81,,,percent of total billed charges,,,13377.92,,,percent of total billed charges,,,,,,,,,,,,,,,5166.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,317.52,,,fee schedule,,,141.57,,,fee schedule,,,,,,,,,,,,,,,2066.49,,,percent of total billed charges,,,25831.08,,,percent of total billed charges,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,25831.08,,,percent of total billed charges,,,25831.08,,,percent of total billed charges,,,,,,,,,25831.08,,,fee schedule,,,151.06,,,fee schedule,,,,,,,,,,,,,,,132.84,,,fee schedule,,,177.12,,,fee schedule,,,98.19,,,fee schedule,,,163.41,,,fee schedule,,,25831.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,25831.08,,,percent of total billed charges,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12915.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,18138.58,,,percent of total billed charges,,
TENECTEPLACE PER 50 MG INJ,2500005770,CDM,636,RC,J3101,HCPCS,5024212047,NDC,9002,APC,,outpatient,facility,10,ML,25831.08,25831.08,155.93,9454.18,,,,,,,,167.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,162.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.05,,,fee schedule,,,,,,,,,9454.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,162.43,,,fee schedule,,,,,,,,,,,,,,,162.43,,,fee schedule,,,170.55,,,fee schedule,,,,,,,,,162.43,,,fee schedule,,,162.43,,,fee schedule,,,170.55,,,fee schedule,,,,,,,,,,,,,,,235.52,,,fee schedule,,,,,,,,,,,,,,,162.43,,,fee schedule,,,,,,,,,,,,,,,155.93,,,fee schedule,,,173.8,,,fee schedule,,,170.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.43,,,fee schedule,,,162.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,168.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,203.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,203.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,162.43,,,fee schedule,,,162.43,,,fee schedule,,,,,,,,,,,,,,,162.43,,,fee schedule,,,,,,,,,,,,,,,162.43,,,fee schedule,,,167.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.72,,,fee schedule,,,162.43,,,fee schedule,,,168.93,,,fee schedule,,,162.43,,,fee schedule,,,,,,,,,162.43,,,fee schedule,,,,,,,,,162.43,,,fee schedule,,,,,,,,
TENECTEPLACE PER 50 MG INJ,2500005770,CDM,636,RC,J3101,HCPCS,5024212047,NDC,999,EAPG,,outpatient,facility,10,ML,25831.08,25831.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALTEPLASE RECOMB IV 2 MG,2500005891,CDM,636,RC,J2997,HCPCS,5024204164,NDC,,,,inpatient,facility,2,GR,581.95,581.95,46.56,581.95,,,,,,,,,,,,,,581.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.76,,,percent of total billed charges,,,,,,,,,581.95,,,percent of total billed charges,,,322.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,581.95,,,percent of total billed charges,,,,,,,,,,,,,,,581.95,,,percent of total billed charges,,,303.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.56,,,percent of total billed charges,,,581.95,,,percent of total billed charges,,,581.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,581.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,408.65,,,percent of total billed charges,,
ALTEPLASE RECOMB IV 2 MG,2500005891,CDM,636,RC,J2997,HCPCS,5024204164,NDC,,,,outpatient,facility,2,GR,581.95,581.95,46.56,618.77,,339.86,,,percent of total billed charges,,,,,,,,,581.95,,,percent of total billed charges,,,107.96,,,fee schedule,,,104.04,,,fee schedule,,,,,,,,,104.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,581.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,523.76,,,percent of total billed charges,,,,,,,,,581.95,,,percent of total billed charges,,,394.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.94,,,percent of total billed charges,,,,,,,,,,,,,,,88.97,,,fee schedule,,,88.97,,,fee schedule,,,,,,,,,618.77,,,per diem,,,581.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,303.43,,,percent of total billed charges,,,581.95,,,percent of total billed charges,,,581.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.28,,,percent of total billed charges,,,220.44,,,percent of total billed charges,,,301.39,,,percent of total billed charges,,,,,,,,,,,,,,,116.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,194.28,,,fee schedule,,,86.62,,,fee schedule,,,,,,,,,,,,,,,46.56,,,percent of total billed charges,,,581.95,,,percent of total billed charges,,,581.95,,,percent of total billed charges,,,,,,,,,,,,,,,581.95,,,percent of total billed charges,,,581.95,,,percent of total billed charges,,,,,,,,,581.95,,,fee schedule,,,92.43,,,fee schedule,,,,,,,,,,,,,,,81.28,,,fee schedule,,,108.37,,,fee schedule,,,60.08,,,fee schedule,,,94.79,,,fee schedule,,,581.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,581.95,,,percent of total billed charges,,,581.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,408.65,,,percent of total billed charges,,
ALTEPLASE RECOMB IV 2 MG,2500005891,CDM,636,RC,J2997,HCPCS,5024204164,NDC,7048,APC,,outpatient,facility,2,GR,581.95,581.95,87.82,212.99,,,,,,,,94.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.39,,,fee schedule,,,,,,,,,212.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,91.48,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,91.48,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,,,,,,,,132.65,,,fee schedule,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,87.82,,,fee schedule,,,97.88,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,91.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,95.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,114.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,91.48,,,fee schedule,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,91.48,,,fee schedule,,,94.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.47,,,fee schedule,,,91.48,,,fee schedule,,,95.14,,,fee schedule,,,91.48,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,,,,,,
ALTEPLASE RECOMB IV 2 MG,2500005891,CDM,636,RC,J2997,HCPCS,5024204164,NDC,436,EAPG,,outpatient,facility,2,GR,581.95,581.95,126.95,186.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.11,,,fee schedule,,,126.95,,,fee schedule,,,165.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALTEPLASE RECOMB IV 50 MG,2500005897,CDM,636,RC,J2997,HCPCS,5024204413,NDC,,,,inpatient,facility,50,GR,14520.59,14520.59,1161.65,14520.59,,,,,,,,,,,,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13068.53,,,percent of total billed charges,,,,,,,,,14520.59,,,percent of total billed charges,,,8038.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13248.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,14520.59,,,percent of total billed charges,,,7571.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2904.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.65,,,percent of total billed charges,,,14520.59,,,percent of total billed charges,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10196.36,,,percent of total billed charges,,
ALTEPLASE RECOMB IV 50 MG,2500005897,CDM,636,RC,J2997,HCPCS,5024204413,NDC,,,,outpatient,facility,50,GR,14520.59,14520.59,60.08,14520.59,,8480.02,,,percent of total billed charges,,,,,,,,,14520.59,,,percent of total billed charges,,,107.96,,,fee schedule,,,104.04,,,fee schedule,,,,,,,,,104.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13068.53,,,percent of total billed charges,,,,,,,,,14520.59,,,percent of total billed charges,,,9833.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11151.81,,,percent of total billed charges,,,,,,,,,,,,,,,88.97,,,fee schedule,,,88.97,,,fee schedule,,,,,,,,,618.77,,,per diem,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7571.04,,,percent of total billed charges,,,14520.59,,,percent of total billed charges,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11035.65,,,percent of total billed charges,,,5500.4,,,percent of total billed charges,,,7520.21,,,percent of total billed charges,,,,,,,,,,,,,,,2904.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,194.28,,,fee schedule,,,86.62,,,fee schedule,,,,,,,,,,,,,,,1161.65,,,percent of total billed charges,,,14520.59,,,percent of total billed charges,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,14520.59,,,percent of total billed charges,,,14520.59,,,percent of total billed charges,,,,,,,,,14520.59,,,fee schedule,,,92.43,,,fee schedule,,,,,,,,,,,,,,,81.28,,,fee schedule,,,108.37,,,fee schedule,,,60.08,,,fee schedule,,,94.79,,,fee schedule,,,14520.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14520.59,,,percent of total billed charges,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7260.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10196.36,,,percent of total billed charges,,
ALTEPLASE RECOMB IV 50 MG,2500005897,CDM,636,RC,J2997,HCPCS,5024204413,NDC,7048,APC,,outpatient,facility,50,GR,14520.59,14520.59,87.82,5314.54,,,,,,,,94.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.39,,,fee schedule,,,,,,,,,5314.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,91.48,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,91.48,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,,,,,,,,132.65,,,fee schedule,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,87.82,,,fee schedule,,,97.88,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,91.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,95.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,114.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,91.48,,,fee schedule,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,91.48,,,fee schedule,,,94.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.47,,,fee schedule,,,91.48,,,fee schedule,,,95.14,,,fee schedule,,,91.48,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,,,,,,
ALTEPLASE RECOMB IV 50 MG,2500005897,CDM,636,RC,J2997,HCPCS,5024204413,NDC,436,EAPG,,outpatient,facility,50,GR,14520.59,14520.59,809.19,1186.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1186.27,,,fee schedule,,,809.19,,,fee schedule,,,1054.61,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,809.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,809.19,,,fee schedule,,,809.19,,,fee schedule,,,809.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,809.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,809.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALTEPLASE RECOMB IV 100 MG,2500005898,CDM,636,RC,J2997,HCPCS,5024208527,NDC,,,,inpatient,facility,100,ML,29041.19,29041.19,2323.3,29041.19,,,,,,,,,,,,,,29041.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26137.07,,,percent of total billed charges,,,,,,,,,29041.19,,,percent of total billed charges,,,16077.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26497.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29041.19,,,percent of total billed charges,,,,,,,,,,,,,,,29041.19,,,percent of total billed charges,,,15142.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5808.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2323.3,,,percent of total billed charges,,,29041.19,,,percent of total billed charges,,,29041.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29041.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20392.72,,,percent of total billed charges,,
ALTEPLASE RECOMB IV 100 MG,2500005898,CDM,636,RC,J2997,HCPCS,5024208527,NDC,,,,outpatient,facility,100,ML,29041.19,29041.19,60.08,29041.19,,16960.05,,,percent of total billed charges,,,,,,,,,29041.19,,,percent of total billed charges,,,107.96,,,fee schedule,,,104.04,,,fee schedule,,,,,,,,,104.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,29041.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26137.07,,,percent of total billed charges,,,,,,,,,29041.19,,,percent of total billed charges,,,19666.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22303.63,,,percent of total billed charges,,,,,,,,,,,,,,,88.97,,,fee schedule,,,88.97,,,fee schedule,,,,,,,,,618.77,,,per diem,,,29041.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15142.08,,,percent of total billed charges,,,29041.19,,,percent of total billed charges,,,29041.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22071.3,,,percent of total billed charges,,,11000.8,,,percent of total billed charges,,,15040.43,,,percent of total billed charges,,,,,,,,,,,,,,,5808.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,194.28,,,fee schedule,,,86.62,,,fee schedule,,,,,,,,,,,,,,,2323.3,,,percent of total billed charges,,,29041.19,,,percent of total billed charges,,,29041.19,,,percent of total billed charges,,,,,,,,,,,,,,,29041.19,,,percent of total billed charges,,,29041.19,,,percent of total billed charges,,,,,,,,,29041.19,,,fee schedule,,,92.43,,,fee schedule,,,,,,,,,,,,,,,81.28,,,fee schedule,,,108.37,,,fee schedule,,,60.08,,,fee schedule,,,94.79,,,fee schedule,,,29041.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,29041.19,,,percent of total billed charges,,,29041.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14520.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20392.72,,,percent of total billed charges,,
ALTEPLASE RECOMB IV 100 MG,2500005898,CDM,636,RC,J2997,HCPCS,5024208527,NDC,7048,APC,,outpatient,facility,100,ML,29041.19,29041.19,87.82,10629.08,,,,,,,,94.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.39,,,fee schedule,,,,,,,,,10629.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,91.48,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,91.48,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,,,,,,,,132.65,,,fee schedule,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,87.82,,,fee schedule,,,97.88,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,91.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,95.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,114.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,91.48,,,fee schedule,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,91.48,,,fee schedule,,,94.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.47,,,fee schedule,,,91.48,,,fee schedule,,,95.14,,,fee schedule,,,91.48,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,,,,,,
ALTEPLASE RECOMB IV 100 MG,2500005898,CDM,636,RC,J2997,HCPCS,5024208527,NDC,436,EAPG,,outpatient,facility,100,ML,29041.19,29041.19,4243.6,6221.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6221.12,,,fee schedule,,,4243.6,,,fee schedule,,,5530.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4243.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4243.6,,,fee schedule,,,4243.6,,,fee schedule,,,4243.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4243.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,4243.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMIODARONE HCL IV 150 MG,2500005905,CDM,636,RC,J0282,HCPCS,4306615010,NDC,,,,inpatient,facility,100,UN,114.48,114.48,9.16,114.48,,,,,,,,,,,,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.03,,,percent of total billed charges,,,,,,,,,114.48,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,114.48,,,percent of total billed charges,,,59.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,114.48,,,percent of total billed charges,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.39,,,percent of total billed charges,,
AMIODARONE HCL IV 150 MG,2500005905,CDM,636,RC,J0282,HCPCS,4306615010,NDC,,,,outpatient,facility,100,UN,114.48,114.48,0.85,618.77,,66.86,,,percent of total billed charges,,,22.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,114.48,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,41.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,103.03,,,percent of total billed charges,,,,,,,,,114.48,,,percent of total billed charges,,,77.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.69,,,percent of total billed charges,,,114.48,,,percent of total billed charges,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87,,,percent of total billed charges,,,43.37,,,percent of total billed charges,,,59.29,,,percent of total billed charges,,,,,,,,,,,,,,,22.9,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,114.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,114.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.16,,,percent of total billed charges,,,114.48,,,percent of total billed charges,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,114.48,,,percent of total billed charges,,,114.48,,,percent of total billed charges,,,,,,,,,114.48,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,114.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,114.48,,,percent of total billed charges,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,80.39,,,percent of total billed charges,,
AMIODARONE HCL IV 150 MG,2500005905,CDM,636,RC,J0282,HCPCS,4306615010,NDC,435,EAPG,,outpatient,facility,100,UN,114.48,114.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IRON SUCROSE INJ 100 MG,2500006050,CDM,636,RC,J1756,HCPCS,517234010,NDC,,,,inpatient,facility,5,ML,202.02,202.02,16.16,202.02,,,,,,,,,,,,,,202.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.82,,,percent of total billed charges,,,,,,,,,202.02,,,percent of total billed charges,,,111.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.02,,,percent of total billed charges,,,,,,,,,,,,,,,202.02,,,percent of total billed charges,,,105.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.16,,,percent of total billed charges,,,202.02,,,percent of total billed charges,,,202.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,202.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.86,,,percent of total billed charges,,
IRON SUCROSE INJ 100 MG,2500006050,CDM,636,RC,J1756,HCPCS,517234010,NDC,,,,outpatient,facility,5,ML,202.02,202.02,0.24,618.77,,117.98,,,percent of total billed charges,,,39.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,202.02,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,202.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,73.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,181.82,,,percent of total billed charges,,,,,,,,,202.02,,,percent of total billed charges,,,136.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,202.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,105.33,,,percent of total billed charges,,,202.02,,,percent of total billed charges,,,202.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.54,,,percent of total billed charges,,,76.53,,,percent of total billed charges,,,104.63,,,percent of total billed charges,,,,,,,,,,,,,,,40.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,202.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,202.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.16,,,percent of total billed charges,,,202.02,,,percent of total billed charges,,,202.02,,,percent of total billed charges,,,,,,,,,,,,,,,202.02,,,percent of total billed charges,,,202.02,,,percent of total billed charges,,,,,,,,,202.02,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.24,,,fee schedule,,,202.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,202.02,,,percent of total billed charges,,,202.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,141.86,,,percent of total billed charges,,
IRON SUCROSE INJ 100 MG,2500006050,CDM,636,RC,J1756,HCPCS,517234010,NDC,435,EAPG,,outpatient,facility,5,ML,202.02,202.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUTEROL HFA 6.7 GM INHALER,2500006085,CDM,637,RC,6909714260,NDC,,,,,,inpatient,facility,6.7,UN,244.27,244.27,19.54,244.27,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.84,,,percent of total billed charges,,,,,,,,,244.27,,,percent of total billed charges,,,135.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,127.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.54,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.53,,,percent of total billed charges,,
ALBUTEROL HFA 6.7 GM INHALER,2500006085,CDM,637,RC,6909714260,NDC,,,,,,outpatient,facility,6.7,UN,244.27,244.27,19.54,618.77,,142.65,,,percent of total billed charges,,,47.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,244.27,,,percent of total billed charges,,,215.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,215.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,215.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,89.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,219.84,,,percent of total billed charges,,,,,,,,,244.27,,,percent of total billed charges,,,165.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.6,,,percent of total billed charges,,,,,,,,,,,,,,,131.91,,,percent of total billed charges,,,131.91,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,127.36,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.65,,,percent of total billed charges,,,92.53,,,percent of total billed charges,,,126.51,,,percent of total billed charges,,,,,,,,,,,,,,,48.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,90.38,,,percent of total billed charges,,,90.38,,,percent of total billed charges,,,244.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,244.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.54,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,,,,,,,244.27,,,fee schedule,,,227.22,,,percent of total billed charges,,,,,,,,,,,,,,,227.22,,,percent of total billed charges,,,227.22,,,percent of total billed charges,,,227.22,,,percent of total billed charges,,,183.2,,,percent of total billed charges,,,244.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,244.27,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,171.53,,,percent of total billed charges,,
ALBUTEROL HFA 6.7 GM INHALER,2500006085,CDM,637,RC,6909714260,NDC,999,EAPG,,,,outpatient,facility,6.7,UN,244.27,244.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUTEROL 8 GM INH,2500006089,CDM,637,RC,173068224,NDC,,,,,,inpatient,facility,1,UN,74.98,74.98,6,74.98,,,,,,,,,,,,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.48,,,percent of total billed charges,,,,,,,,,74.98,,,percent of total billed charges,,,41.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,74.98,,,percent of total billed charges,,,39.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.65,,,percent of total billed charges,,
ALBUTEROL 8 GM INH,2500006089,CDM,637,RC,173068224,NDC,,,,,,outpatient,facility,1,UN,74.98,74.98,6,618.77,,43.79,,,percent of total billed charges,,,14.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,74.98,,,percent of total billed charges,,,66.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,66.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,66.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,27.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,67.48,,,percent of total billed charges,,,,,,,,,74.98,,,percent of total billed charges,,,50.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.58,,,percent of total billed charges,,,,,,,,,,,,,,,40.49,,,percent of total billed charges,,,40.49,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.09,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.98,,,percent of total billed charges,,,28.4,,,percent of total billed charges,,,38.83,,,percent of total billed charges,,,,,,,,,,,,,,,15,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,27.74,,,percent of total billed charges,,,27.74,,,percent of total billed charges,,,74.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,74.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,74.98,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,74.98,,,fee schedule,,,69.75,,,percent of total billed charges,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,69.75,,,percent of total billed charges,,,69.75,,,percent of total billed charges,,,56.23,,,percent of total billed charges,,,74.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,74.98,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,52.65,,,percent of total billed charges,,
ALBUTEROL 8 GM INH,2500006089,CDM,637,RC,173068224,NDC,999,EAPG,,,,outpatient,facility,1,UN,74.98,74.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACARBOSE 25 MG TAB,2500006322,CDM,637,RC,54014025,NDC,,,,,,inpatient,facility,25,UN,3,3,0.24,3,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,,,,,,,3,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,
ACARBOSE 25 MG TAB,2500006322,CDM,637,RC,54014025,NDC,,,,,,outpatient,facility,25,UN,3,3,0.24,618.77,,1.75,,,percent of total billed charges,,,0.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3,,,percent of total billed charges,,,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.7,,,percent of total billed charges,,,,,,,,,3,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.11,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,3,,,fee schedule,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,2.79,,,percent of total billed charges,,,2.79,,,percent of total billed charges,,,2.79,,,percent of total billed charges,,,2.25,,,percent of total billed charges,,,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.11,,,percent of total billed charges,,
ACARBOSE 25 MG TAB,2500006322,CDM,637,RC,54014025,NDC,999,EAPG,,,,outpatient,facility,25,UN,3,3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAMIN/BUTALBITAL/CAFF  TAB,2500006350,CDM,637,RC,904693806,NDC,,,,,,inpatient,facility,1,UN,5.97,5.97,0.48,5.97,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.37,,,percent of total billed charges,,,,,,,,,5.97,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,3.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,
ACETAMIN/BUTALBITAL/CAFF  TAB,2500006350,CDM,637,RC,904693806,NDC,,,,,,outpatient,facility,1,UN,5.97,5.97,0.48,618.77,,3.49,,,percent of total billed charges,,,1.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.97,,,percent of total billed charges,,,5.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.37,,,percent of total billed charges,,,,,,,,,5.97,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,3.22,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.11,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.54,,,percent of total billed charges,,,2.26,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,5.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.48,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,5.97,,,fee schedule,,,5.55,,,percent of total billed charges,,,,,,,,,,,,,,,5.55,,,percent of total billed charges,,,5.55,,,percent of total billed charges,,,5.55,,,percent of total billed charges,,,4.48,,,percent of total billed charges,,,5.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.97,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.19,,,percent of total billed charges,,
ACETAMIN/BUTALBITAL/CAFF  TAB,2500006350,CDM,637,RC,904693806,NDC,999,EAPG,,,,outpatient,facility,1,UN,5.97,5.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAMINOPHEN 120 MG SUPP,2500006360,CDM,637,RC,4580273230,NDC,,,,,,inpatient,facility,120,UN,1.92,1.92,0.15,1.92,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,,,,,,,1.92,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,
ACETAMINOPHEN 120 MG SUPP,2500006360,CDM,637,RC,4580273230,NDC,,,,,,outpatient,facility,120,UN,1.92,1.92,0.15,618.77,,1.12,,,percent of total billed charges,,,0.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.92,,,percent of total billed charges,,,1.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.73,,,percent of total billed charges,,,,,,,,,1.92,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.46,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.71,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,1.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,1.92,,,fee schedule,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.79,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.35,,,percent of total billed charges,,
ACETAMINOPHEN 120 MG SUPP,2500006360,CDM,637,RC,4580273230,NDC,999,EAPG,,,,outpatient,facility,120,UN,1.92,1.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAMINOPHEN 325 MG TAB,2500006363,CDM,637,RC,904677361,NDC,,,,,,inpatient,facility,325,UN,1.97,1.97,0.16,1.97,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,1.97,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,
ACETAMINOPHEN 325 MG TAB,2500006363,CDM,637,RC,904677361,NDC,,,,,,outpatient,facility,325,UN,1.97,1.97,0.16,618.77,,1.15,,,percent of total billed charges,,,0.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.97,,,percent of total billed charges,,,1.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.77,,,percent of total billed charges,,,,,,,,,1.97,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,1.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,,,,,,,1.97,,,fee schedule,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,1.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.97,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.38,,,percent of total billed charges,,
ACETAMINOPHEN 325 MG TAB,2500006363,CDM,637,RC,904677361,NDC,999,EAPG,,,,outpatient,facility,325,UN,1.97,1.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAMINOPHEN 650 MG SUPP,2500006367,CDM,637,RC,4580273030,NDC,,,,,,inpatient,facility,650,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
ACETAMINOPHEN 650 MG SUPP,2500006367,CDM,637,RC,4580273030,NDC,,,,,,outpatient,facility,650,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
ACETAMINOPHEN 650 MG SUPP,2500006367,CDM,637,RC,4580273030,NDC,999,EAPG,,,,outpatient,facility,650,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAMINOPHEN 650 MG/20.3 ML,2500006368,CDM,637,RC,904682076,NDC,,,,,,inpatient,facility,20.3,UN,2.55,2.55,0.2,2.55,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.29,,,percent of total billed charges,,,,,,,,,2.55,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.79,,,percent of total billed charges,,
ACETAMINOPHEN 650 MG/20.3 ML,2500006368,CDM,637,RC,904682076,NDC,,,,,,outpatient,facility,20.3,UN,2.55,2.55,0.2,618.77,,1.49,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.55,,,percent of total billed charges,,,2.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.29,,,percent of total billed charges,,,,,,,,,2.55,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.94,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,2.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,2.55,,,fee schedule,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,2.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.79,,,percent of total billed charges,,
ACETAMINOPHEN 650 MG/20.3 ML,2500006368,CDM,637,RC,904682076,NDC,999,EAPG,,,,outpatient,facility,20.3,UN,2.55,2.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAZOLAMIDE 250 MG TAB,2500006400,CDM,637,RC,2315528801,NDC,,,,,,inpatient,facility,250,UN,9.5,9.5,0.76,9.5,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.55,,,percent of total billed charges,,,,,,,,,9.5,,,percent of total billed charges,,,5.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.67,,,percent of total billed charges,,
ACETAZOLAMIDE 250 MG TAB,2500006400,CDM,637,RC,2315528801,NDC,,,,,,outpatient,facility,250,UN,9.5,9.5,0.76,618.77,,5.55,,,percent of total billed charges,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.5,,,percent of total billed charges,,,8.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,8.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,8.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.55,,,percent of total billed charges,,,,,,,,,9.5,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.3,,,percent of total billed charges,,,,,,,,,,,,,,,5.13,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.52,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,9.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.76,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,9.5,,,fee schedule,,,8.84,,,percent of total billed charges,,,,,,,,,,,,,,,8.84,,,percent of total billed charges,,,8.84,,,percent of total billed charges,,,8.84,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,9.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.5,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.67,,,percent of total billed charges,,
ACETAZOLAMIDE 250 MG TAB,2500006400,CDM,637,RC,2315528801,NDC,999,EAPG,,,,outpatient,facility,250,UN,9.5,9.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETIC ACID 5  500 ML PLCT,2500006446,CDM,637,RC,5155200516,NDC,,,,,,inpatient,facility,500,UN,221.56,221.56,17.72,221.56,,,,,,,,,,,,,,221.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.4,,,percent of total billed charges,,,,,,,,,221.56,,,percent of total billed charges,,,122.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.56,,,percent of total billed charges,,,,,,,,,,,,,,,221.56,,,percent of total billed charges,,,115.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.72,,,percent of total billed charges,,,221.56,,,percent of total billed charges,,,221.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,221.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.58,,,percent of total billed charges,,
ACETIC ACID 5  500 ML PLCT,2500006446,CDM,637,RC,5155200516,NDC,,,,,,outpatient,facility,500,UN,221.56,221.56,17.72,618.77,,129.39,,,percent of total billed charges,,,43.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,221.56,,,percent of total billed charges,,,195.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,195.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,195.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,221.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,81.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,199.4,,,percent of total billed charges,,,,,,,,,221.56,,,percent of total billed charges,,,150.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.16,,,percent of total billed charges,,,,,,,,,,,,,,,119.64,,,percent of total billed charges,,,119.64,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,221.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,115.52,,,percent of total billed charges,,,221.56,,,percent of total billed charges,,,221.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.39,,,percent of total billed charges,,,83.93,,,percent of total billed charges,,,114.75,,,percent of total billed charges,,,,,,,,,,,,,,,44.31,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,81.98,,,percent of total billed charges,,,81.98,,,percent of total billed charges,,,221.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,221.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.72,,,percent of total billed charges,,,221.56,,,percent of total billed charges,,,221.56,,,percent of total billed charges,,,,,,,,,,,,,,,221.56,,,percent of total billed charges,,,221.56,,,percent of total billed charges,,,,,,,,,221.56,,,fee schedule,,,206.1,,,percent of total billed charges,,,,,,,,,,,,,,,206.1,,,percent of total billed charges,,,206.1,,,percent of total billed charges,,,206.1,,,percent of total billed charges,,,166.17,,,percent of total billed charges,,,221.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,221.56,,,percent of total billed charges,,,221.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,155.58,,,percent of total billed charges,,
ACETIC ACID 5  500 ML PLCT,2500006446,CDM,637,RC,5155200516,NDC,999,EAPG,,,,outpatient,facility,500,UN,221.56,221.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACYCLOVIR 200 MG CAP,2500006500,CDM,637,RC,904578961,NDC,,,,,,inpatient,facility,200,UN,0.43,0.43,0.03,0.43,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,
ACYCLOVIR 200 MG CAP,2500006500,CDM,637,RC,904578961,NDC,,,,,,outpatient,facility,200,UN,0.43,0.43,0.03,618.77,,0.25,,,percent of total billed charges,,,0.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.43,,,percent of total billed charges,,,0.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.39,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.16,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,0.43,,,fee schedule,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,0.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.3,,,percent of total billed charges,,
ACYCLOVIR 200 MG CAP,2500006500,CDM,637,RC,904578961,NDC,999,EAPG,,,,outpatient,facility,200,UN,0.43,0.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACYCLOVIR 5  OINT 15 GM,2500006506,CDM,637,RC,6516283594,NDC,,,,,,inpatient,facility,15,UN,1316.04,1316.04,105.28,1316.04,,,,,,,,,,,,,,1316.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1184.44,,,percent of total billed charges,,,,,,,,,1316.04,,,percent of total billed charges,,,728.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1200.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1316.04,,,percent of total billed charges,,,,,,,,,,,,,,,1316.04,,,percent of total billed charges,,,686.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.28,,,percent of total billed charges,,,1316.04,,,percent of total billed charges,,,1316.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1316.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,924.12,,,percent of total billed charges,,
ACYCLOVIR 5  OINT 15 GM,2500006506,CDM,637,RC,6516283594,NDC,,,,,,outpatient,facility,15,UN,1316.04,1316.04,105.28,1316.04,,768.57,,,percent of total billed charges,,,256.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1316.04,,,percent of total billed charges,,,1158.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1158.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1158.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1316.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,481.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1184.44,,,percent of total billed charges,,,,,,,,,1316.04,,,percent of total billed charges,,,891.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1010.72,,,percent of total billed charges,,,,,,,,,,,,,,,710.66,,,percent of total billed charges,,,710.66,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1316.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,686.18,,,percent of total billed charges,,,1316.04,,,percent of total billed charges,,,1316.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1000.19,,,percent of total billed charges,,,498.52,,,percent of total billed charges,,,681.58,,,percent of total billed charges,,,,,,,,,,,,,,,263.21,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,486.93,,,percent of total billed charges,,,486.93,,,percent of total billed charges,,,1316.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1316.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,105.28,,,percent of total billed charges,,,1316.04,,,percent of total billed charges,,,1316.04,,,percent of total billed charges,,,,,,,,,,,,,,,1316.04,,,percent of total billed charges,,,1316.04,,,percent of total billed charges,,,,,,,,,1316.04,,,fee schedule,,,1224.18,,,percent of total billed charges,,,,,,,,,,,,,,,1224.18,,,percent of total billed charges,,,1224.18,,,percent of total billed charges,,,1224.18,,,percent of total billed charges,,,987.03,,,percent of total billed charges,,,1316.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1316.04,,,percent of total billed charges,,,1316.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,658.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,924.12,,,percent of total billed charges,,
ACYCLOVIR 5  OINT 15 GM,2500006506,CDM,637,RC,6516283594,NDC,999,EAPG,,,,outpatient,facility,15,UN,1316.04,1316.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACYCLOVIR 800 MG TAB,2500006508,CDM,637,RC,3172277801,NDC,,,,,,inpatient,facility,800,UN,13.93,13.93,1.11,13.93,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.54,,,percent of total billed charges,,,,,,,,,13.93,,,percent of total billed charges,,,7.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,7.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,
ACYCLOVIR 800 MG TAB,2500006508,CDM,637,RC,3172277801,NDC,,,,,,outpatient,facility,800,UN,13.93,13.93,1.11,618.77,,8.14,,,percent of total billed charges,,,2.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.93,,,percent of total billed charges,,,12.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.54,,,percent of total billed charges,,,,,,,,,13.93,,,percent of total billed charges,,,9.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.7,,,percent of total billed charges,,,,,,,,,,,,,,,7.52,,,percent of total billed charges,,,7.52,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.26,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.59,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,7.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.79,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.15,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,13.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.11,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,13.93,,,fee schedule,,,12.96,,,percent of total billed charges,,,,,,,,,,,,,,,12.96,,,percent of total billed charges,,,12.96,,,percent of total billed charges,,,12.96,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,13.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.78,,,percent of total billed charges,,
ACYCLOVIR 800 MG TAB,2500006508,CDM,637,RC,3172277801,NDC,999,EAPG,,,,outpatient,facility,800,UN,13.93,13.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUTEROL HFA 8 .5 GM INH,2500006578,CDM,637,RC,93317431,NDC,,,,,,inpatient,facility,8.5,UN,244.27,244.27,19.54,244.27,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.84,,,percent of total billed charges,,,,,,,,,244.27,,,percent of total billed charges,,,135.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,127.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.54,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.53,,,percent of total billed charges,,
ALBUTEROL HFA 8 .5 GM INH,2500006578,CDM,637,RC,93317431,NDC,,,,,,outpatient,facility,8.5,UN,244.27,244.27,19.54,618.77,,142.65,,,percent of total billed charges,,,47.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,244.27,,,percent of total billed charges,,,215.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,215.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,215.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,89.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,219.84,,,percent of total billed charges,,,,,,,,,244.27,,,percent of total billed charges,,,165.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.6,,,percent of total billed charges,,,,,,,,,,,,,,,131.91,,,percent of total billed charges,,,131.91,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,127.36,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.65,,,percent of total billed charges,,,92.53,,,percent of total billed charges,,,126.51,,,percent of total billed charges,,,,,,,,,,,,,,,48.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,90.38,,,percent of total billed charges,,,90.38,,,percent of total billed charges,,,244.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,244.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.54,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,,,,,,,244.27,,,fee schedule,,,227.22,,,percent of total billed charges,,,,,,,,,,,,,,,227.22,,,percent of total billed charges,,,227.22,,,percent of total billed charges,,,227.22,,,percent of total billed charges,,,183.2,,,percent of total billed charges,,,244.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,244.27,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,171.53,,,percent of total billed charges,,
ALBUTEROL HFA 8 .5 GM INH,2500006578,CDM,637,RC,93317431,NDC,999,EAPG,,,,outpatient,facility,8.5,UN,244.27,244.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOPURINOL 100 MG TAB,2500006630,CDM,637,RC,904704161,NDC,,,,,,inpatient,facility,100,GR,1.09,1.09,0.09,1.09,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,
ALLOPURINOL 100 MG TAB,2500006630,CDM,637,RC,904704161,NDC,,,,,,outpatient,facility,100,GR,1.09,1.09,0.09,618.77,,0.64,,,percent of total billed charges,,,0.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.09,,,percent of total billed charges,,,0.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.98,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,1.09,,,fee schedule,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,1.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.77,,,percent of total billed charges,,
ALLOPURINOL 100 MG TAB,2500006630,CDM,637,RC,904704161,NDC,999,EAPG,,,,outpatient,facility,100,GR,1.09,1.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOPURINOL 300 MG TAB,2500006633,CDM,637,RC,904657261,NDC,,,,,,inpatient,facility,300,UN,2.21,2.21,0.18,2.21,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,
ALLOPURINOL 300 MG TAB,2500006633,CDM,637,RC,904657261,NDC,,,,,,outpatient,facility,300,UN,2.21,2.21,0.18,618.77,,1.29,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.21,,,percent of total billed charges,,,1.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.99,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,2.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,2.21,,,fee schedule,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,2.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.55,,,percent of total billed charges,,
ALLOPURINOL 300 MG TAB,2500006633,CDM,637,RC,904657261,NDC,999,EAPG,,,,outpatient,facility,300,UN,2.21,2.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALPRAZOLAM 0.25 MG TAB,2500006660,CDM,637,RC,6586267601,NDC,,,,,,inpatient,facility,0.25,UN,2.31,2.31,0.18,2.31,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,
ALPRAZOLAM 0.25 MG TAB,2500006660,CDM,637,RC,6586267601,NDC,,,,,,outpatient,facility,0.25,UN,2.31,2.31,0.18,618.77,,1.35,,,percent of total billed charges,,,0.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.31,,,percent of total billed charges,,,2.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.08,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.85,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,2.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,2.31,,,fee schedule,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,2.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.62,,,percent of total billed charges,,
ALPRAZOLAM 0.25 MG TAB,2500006660,CDM,637,RC,6586267601,NDC,999,EAPG,,,,outpatient,facility,0.25,UN,2.31,2.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALPRAZOLAM 0.5 MG TAB,2500006662,CDM,637,RC,6586267701,NDC,,,,,,inpatient,facility,0.5,UN,3.07,3.07,0.25,3.07,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,,,,,,,3.07,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,
ALPRAZOLAM 0.5 MG TAB,2500006662,CDM,637,RC,6586267701,NDC,,,,,,outpatient,facility,0.5,UN,3.07,3.07,0.25,618.77,,1.79,,,percent of total billed charges,,,0.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.07,,,percent of total billed charges,,,2.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.76,,,percent of total billed charges,,,,,,,,,3.07,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.14,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,3.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.25,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,3.07,,,fee schedule,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,3.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.16,,,percent of total billed charges,,
ALPRAZOLAM 0.5 MG TAB,2500006662,CDM,637,RC,6586267701,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,3.07,3.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMANTADINE 100 MG CAP,2500006762,CDM,637,RC,G9017,HCPCS,904704206,NDC,,,,inpatient,facility,100,UN,4.62,4.62,0.37,4.62,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,4.62,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.24,,,percent of total billed charges,,
AMANTADINE 100 MG CAP,2500006762,CDM,637,RC,G9017,HCPCS,904704206,NDC,,,,outpatient,facility,100,UN,4.62,4.62,0.37,618.77,,2.7,,,percent of total billed charges,,,0.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.62,,,percent of total billed charges,,,4.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.16,,,percent of total billed charges,,,,,,,,,4.62,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.55,,,percent of total billed charges,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.71,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,4.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,4.62,,,fee schedule,,,4.3,,,percent of total billed charges,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,4.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.24,,,percent of total billed charges,,
AMANTADINE 100 MG CAP,2500006762,CDM,637,RC,G9017,HCPCS,904704206,NDC,999,EAPG,,outpatient,facility,100,UN,4.62,4.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMILORIDE HCL 5 MG TAB,2500006790,CDM,637,RC,574029201,NDC,,,,,,inpatient,facility,5,UN,0.73,0.73,0.06,0.73,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,0.73,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,
AMILORIDE HCL 5 MG TAB,2500006790,CDM,637,RC,574029201,NDC,,,,,,outpatient,facility,5,UN,0.73,0.73,0.06,618.77,,0.43,,,percent of total billed charges,,,0.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.73,,,percent of total billed charges,,,0.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.66,,,percent of total billed charges,,,,,,,,,0.73,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,0.73,,,fee schedule,,,0.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.51,,,percent of total billed charges,,
AMILORIDE HCL 5 MG TAB,2500006790,CDM,637,RC,574029201,NDC,999,EAPG,,,,outpatient,facility,5,UN,0.73,0.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMINO ACIDS 5 /D15 1000 ML,2500006805,CDM,258,RC,338113703,NDC,,,,,,inpatient,facility,1000,UN,265.32,265.32,21.23,265.32,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.79,,,percent of total billed charges,,,,,,,,,265.32,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,138.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.23,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.31,,,percent of total billed charges,,
AMINO ACIDS 5 /D15 1000 ML,2500006805,CDM,258,RC,338113703,NDC,,,,,,outpatient,facility,1000,UN,265.32,265.32,21.23,618.77,,154.95,,,percent of total billed charges,,,51.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,265.32,,,percent of total billed charges,,,233.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,233.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,233.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,97.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,238.79,,,percent of total billed charges,,,,,,,,,265.32,,,percent of total billed charges,,,179.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,203.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,138.34,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.64,,,percent of total billed charges,,,100.5,,,percent of total billed charges,,,137.41,,,percent of total billed charges,,,,,,,,,,,,,,,53.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,106.13,,,percent of total billed charges,,,106.13,,,percent of total billed charges,,,265.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,265.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.23,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,265.32,,,fee schedule,,,106.13,,,percent of total billed charges,,,,,,,,,,,,,,,106.13,,,percent of total billed charges,,,106.13,,,percent of total billed charges,,,106.13,,,percent of total billed charges,,,198.99,,,percent of total billed charges,,,265.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,186.31,,,percent of total billed charges,,
AMINO ACIDS 5 /D15 1000 ML,2500006805,CDM,258,RC,338113703,NDC,999,EAPG,,,,outpatient,facility,1000,UN,265.32,265.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMINO ACIDS 5 /D15 1000ML LYTE,2500006806,CDM,258,RC,338114703,NDC,,,,,,inpatient,facility,1000,UN,282.68,282.68,22.61,282.68,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.41,,,percent of total billed charges,,,,,,,,,282.68,,,percent of total billed charges,,,156.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,147.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.61,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.5,,,percent of total billed charges,,
AMINO ACIDS 5 /D15 1000ML LYTE,2500006806,CDM,258,RC,338114703,NDC,,,,,,outpatient,facility,1000,UN,282.68,282.68,22.61,618.77,,165.09,,,percent of total billed charges,,,55.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,282.68,,,percent of total billed charges,,,248.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,248.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,248.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,103.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,254.41,,,percent of total billed charges,,,,,,,,,282.68,,,percent of total billed charges,,,191.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,147.39,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.84,,,percent of total billed charges,,,107.08,,,percent of total billed charges,,,146.4,,,percent of total billed charges,,,,,,,,,,,,,,,56.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,113.07,,,percent of total billed charges,,,113.07,,,percent of total billed charges,,,282.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,282.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.61,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,282.68,,,fee schedule,,,113.07,,,percent of total billed charges,,,,,,,,,,,,,,,113.07,,,percent of total billed charges,,,113.07,,,percent of total billed charges,,,113.07,,,percent of total billed charges,,,212.01,,,percent of total billed charges,,,282.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,198.5,,,percent of total billed charges,,
AMINO ACIDS 5 /D15 1000ML LYTE,2500006806,CDM,258,RC,338114703,NDC,999,EAPG,,,,outpatient,facility,1000,UN,282.68,282.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMIODARONE 200 MG TAB,2500006880,CDM,637,RC,904699361,NDC,,,,,,inpatient,facility,200,UN,0.99,0.99,0.08,0.99,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,
AMIODARONE 200 MG TAB,2500006880,CDM,637,RC,904699361,NDC,,,,,,outpatient,facility,200,UN,0.99,0.99,0.08,618.77,,0.58,,,percent of total billed charges,,,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.99,,,percent of total billed charges,,,0.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.89,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,fee schedule,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.7,,,percent of total billed charges,,
AMIODARONE 200 MG TAB,2500006880,CDM,637,RC,904699361,NDC,999,EAPG,,,,outpatient,facility,200,UN,0.99,0.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMIODARONE HCL 150 MG/3 ML AMP,2500006885,CDM,636,RC,J0282,HCPCS,143987525,NDC,,,,inpatient,facility,3,UN,6.6,6.6,0.53,6.6,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,3.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,
AMIODARONE HCL 150 MG/3 ML AMP,2500006885,CDM,636,RC,J0282,HCPCS,143987525,NDC,,,,outpatient,facility,3,UN,6.6,6.6,0.53,618.77,,3.85,,,percent of total billed charges,,,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.6,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.94,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,4.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,3.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,6.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.53,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,6.6,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,6.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.63,,,percent of total billed charges,,
AMIODARONE HCL 150 MG/3 ML AMP,2500006885,CDM,636,RC,J0282,HCPCS,143987525,NDC,435,EAPG,,outpatient,facility,3,UN,6.6,6.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMITRIPTYLINE HCL 10 MG TAB,2500006890,CDM,637,RC,1672917117,NDC,,,,,,inpatient,facility,10,UN,0.99,0.99,0.08,0.99,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,
AMITRIPTYLINE HCL 10 MG TAB,2500006890,CDM,637,RC,1672917117,NDC,,,,,,outpatient,facility,10,UN,0.99,0.99,0.08,618.77,,0.58,,,percent of total billed charges,,,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.99,,,percent of total billed charges,,,0.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.89,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,fee schedule,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.7,,,percent of total billed charges,,
AMITRIPTYLINE HCL 10 MG TAB,2500006890,CDM,637,RC,1672917117,NDC,999,EAPG,,,,outpatient,facility,10,UN,0.99,0.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMITRIPTYLINE HCL 25 MG TAB,2500006892,CDM,637,RC,904020161,NDC,,,,,,inpatient,facility,25,UN,1.42,1.42,0.11,1.42,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,
AMITRIPTYLINE HCL 25 MG TAB,2500006892,CDM,637,RC,904020161,NDC,,,,,,outpatient,facility,25,UN,1.42,1.42,0.11,618.77,,0.83,,,percent of total billed charges,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.42,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.28,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,1.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,1.42,,,fee schedule,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,1.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1,,,percent of total billed charges,,
AMITRIPTYLINE HCL 25 MG TAB,2500006892,CDM,637,RC,904020161,NDC,999,EAPG,,,,outpatient,facility,25,UN,1.42,1.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMLODIPINE BESYLATE 5 MG TAB,2500006915,CDM,637,RC,904637061,NDC,,,,,,inpatient,facility,5,UN,0.26,0.26,0.02,0.26,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,
AMLODIPINE BESYLATE 5 MG TAB,2500006915,CDM,637,RC,904637061,NDC,,,,,,outpatient,facility,5,UN,0.26,0.26,0.02,618.77,,0.15,,,percent of total billed charges,,,0.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,0.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.23,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.1,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,0.26,,,fee schedule,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.18,,,percent of total billed charges,,
AMLODIPINE BESYLATE 5 MG TAB,2500006915,CDM,637,RC,904637061,NDC,999,EAPG,,,,outpatient,facility,5,UN,0.26,0.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMMONIA INHALANT 0.33 ML AMP,2500006920,CDM,637,RC,6777725101,NDC,,,,,,inpatient,facility,0.33,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
AMMONIA INHALANT 0.33 ML AMP,2500006920,CDM,637,RC,6777725101,NDC,,,,,,outpatient,facility,0.33,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
AMMONIA INHALANT 0.33 ML AMP,2500006920,CDM,637,RC,6777725101,NDC,999,EAPG,,,,outpatient,facility,0.33,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICILLIN  250 MG CAP,2500006970,CDM,637,RC,781202001,NDC,,,,,,inpatient,facility,250,UN,0.82,0.82,0.07,0.82,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
AMOXICILLIN  250 MG CAP,2500006970,CDM,637,RC,781202001,NDC,,,,,,outpatient,facility,250,UN,0.82,0.82,0.07,618.77,,0.48,,,percent of total billed charges,,,0.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.82,,,percent of total billed charges,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.74,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,0.82,,,fee schedule,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.58,,,percent of total billed charges,,
AMOXICILLIN  250 MG CAP,2500006970,CDM,637,RC,781202001,NDC,999,EAPG,,,,outpatient,facility,250,UN,0.82,0.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICILLIN  500 MG CAP,2500006975,CDM,637,RC,781261301,NDC,,,,,,inpatient,facility,500,UN,1.42,1.42,0.11,1.42,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,
AMOXICILLIN  500 MG CAP,2500006975,CDM,637,RC,781261301,NDC,,,,,,outpatient,facility,500,UN,1.42,1.42,0.11,618.77,,0.83,,,percent of total billed charges,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.42,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.28,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,1.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,1.42,,,fee schedule,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,1.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1,,,percent of total billed charges,,
AMOXICILLIN  500 MG CAP,2500006975,CDM,637,RC,781261301,NDC,999,EAPG,,,,outpatient,facility,500,UN,1.42,1.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICILLIN 250MG/5 ML UD,2500006986,CDM,637,RC,781604146,NDC,,,,,,inpatient,facility,5,UN,1.08,1.08,0.09,1.08,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,,,,,,,,1.08,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,
AMOXICILLIN 250MG/5 ML UD,2500006986,CDM,637,RC,781604146,NDC,,,,,,outpatient,facility,5,UN,1.08,1.08,0.09,618.77,,0.63,,,percent of total billed charges,,,0.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.08,,,percent of total billed charges,,,0.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.97,,,percent of total billed charges,,,,,,,,,1.08,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,1.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,1.08,,,fee schedule,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1,,,percent of total billed charges,,,1,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,1.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.76,,,percent of total billed charges,,
AMOXICILLIN 250MG/5 ML UD,2500006986,CDM,637,RC,781604146,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.08,1.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICIL/CLAV 500 MG TAB,2500006991,CDM,637,RC,93227434,NDC,,,,,,inpatient,facility,500,UN,12.47,12.47,1,12.47,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.22,,,percent of total billed charges,,,,,,,,,12.47,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.76,,,percent of total billed charges,,
AMOXICIL/CLAV 500 MG TAB,2500006991,CDM,637,RC,93227434,NDC,,,,,,outpatient,facility,500,UN,12.47,12.47,1,618.77,,7.28,,,percent of total billed charges,,,2.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,12.47,,,percent of total billed charges,,,10.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,10.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,10.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.22,,,percent of total billed charges,,,,,,,,,12.47,,,percent of total billed charges,,,8.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.58,,,percent of total billed charges,,,,,,,,,,,,,,,6.73,,,percent of total billed charges,,,6.73,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.48,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,6.46,,,percent of total billed charges,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.61,,,percent of total billed charges,,,4.61,,,percent of total billed charges,,,12.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,,,,,,,12.47,,,fee schedule,,,11.6,,,percent of total billed charges,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,11.6,,,percent of total billed charges,,,11.6,,,percent of total billed charges,,,9.35,,,percent of total billed charges,,,12.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,12.47,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.76,,,percent of total billed charges,,
AMOXICIL/CLAV 500 MG TAB,2500006991,CDM,637,RC,93227434,NDC,999,EAPG,,,,outpatient,facility,500,UN,12.47,12.47,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICIL/CLAV 875 MG TAB,2500006992,CDM,637,RC,93227534,NDC,,,,,,inpatient,facility,875,UN,16.67,16.67,1.33,16.67,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15,,,percent of total billed charges,,,,,,,,,16.67,,,percent of total billed charges,,,9.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,8.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.71,,,percent of total billed charges,,
AMOXICIL/CLAV 875 MG TAB,2500006992,CDM,637,RC,93227534,NDC,,,,,,outpatient,facility,875,UN,16.67,16.67,1.33,618.77,,9.74,,,percent of total billed charges,,,3.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.67,,,percent of total billed charges,,,14.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,14.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,14.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,15,,,percent of total billed charges,,,,,,,,,16.67,,,percent of total billed charges,,,11.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.8,,,percent of total billed charges,,,,,,,,,,,,,,,9,,,percent of total billed charges,,,9,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.69,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.67,,,percent of total billed charges,,,6.31,,,percent of total billed charges,,,8.63,,,percent of total billed charges,,,,,,,,,,,,,,,3.33,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.17,,,percent of total billed charges,,,6.17,,,percent of total billed charges,,,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.33,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,16.67,,,fee schedule,,,15.51,,,percent of total billed charges,,,,,,,,,,,,,,,15.51,,,percent of total billed charges,,,15.51,,,percent of total billed charges,,,15.51,,,percent of total billed charges,,,12.5,,,percent of total billed charges,,,16.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.71,,,percent of total billed charges,,
AMOXICIL/CLAV 875 MG TAB,2500006992,CDM,637,RC,93227534,NDC,999,EAPG,,,,outpatient,facility,875,UN,16.67,16.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPICILLIN 500 MG CAP,2500007012,CDM,637,RC,781214501,NDC,,,,,,inpatient,facility,500,UN,2.14,2.14,0.17,2.14,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,,,,,2.14,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,
AMPICILLIN 500 MG CAP,2500007012,CDM,637,RC,781214501,NDC,,,,,,outpatient,facility,500,UN,2.14,2.14,0.17,618.77,,1.25,,,percent of total billed charges,,,0.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.14,,,percent of total billed charges,,,1.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.93,,,percent of total billed charges,,,,,,,,,2.14,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,2.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,2.14,,,fee schedule,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,2.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.5,,,percent of total billed charges,,
AMPICILLIN 500 MG CAP,2500007012,CDM,637,RC,781214501,NDC,999,EAPG,,,,outpatient,facility,500,UN,2.14,2.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANASTROZOLE 1 MG TAB,2500007080,CDM,637,RC,1672903510,NDC,,,,,,inpatient,facility,1,UN,43.89,43.89,3.51,43.89,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.5,,,percent of total billed charges,,,,,,,,,43.89,,,percent of total billed charges,,,24.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,22.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.82,,,percent of total billed charges,,
ANASTROZOLE 1 MG TAB,2500007080,CDM,637,RC,1672903510,NDC,,,,,,outpatient,facility,1,UN,43.89,43.89,3.51,618.77,,25.63,,,percent of total billed charges,,,8.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,43.89,,,percent of total billed charges,,,38.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,38.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,38.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,39.5,,,percent of total billed charges,,,,,,,,,43.89,,,percent of total billed charges,,,29.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.71,,,percent of total billed charges,,,,,,,,,,,,,,,23.7,,,percent of total billed charges,,,23.7,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.88,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.36,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,22.73,,,percent of total billed charges,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,16.24,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,43.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.51,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,43.89,,,fee schedule,,,40.83,,,percent of total billed charges,,,,,,,,,,,,,,,40.83,,,percent of total billed charges,,,40.83,,,percent of total billed charges,,,40.83,,,percent of total billed charges,,,32.92,,,percent of total billed charges,,,43.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,43.89,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,30.82,,,percent of total billed charges,,
ANASTROZOLE 1 MG TAB,2500007080,CDM,637,RC,1672903510,NDC,999,EAPG,,,,outpatient,facility,1,UN,43.89,43.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
APIXABAN 2.5 MG TAB,2500007145,CDM,637,RC,3089331,NDC,,,,,,inpatient,facility,2.5,UN,32.7,32.7,2.62,32.7,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.43,,,percent of total billed charges,,,,,,,,,32.7,,,percent of total billed charges,,,18.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,17.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.96,,,percent of total billed charges,,
APIXABAN 2.5 MG TAB,2500007145,CDM,637,RC,3089331,NDC,,,,,,outpatient,facility,2.5,UN,32.7,32.7,2.62,618.77,,19.1,,,percent of total billed charges,,,6.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,32.7,,,percent of total billed charges,,,28.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,28.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,28.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,29.43,,,percent of total billed charges,,,,,,,,,32.7,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.11,,,percent of total billed charges,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.05,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.85,,,percent of total billed charges,,,12.39,,,percent of total billed charges,,,16.94,,,percent of total billed charges,,,,,,,,,,,,,,,6.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,12.1,,,percent of total billed charges,,,12.1,,,percent of total billed charges,,,32.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.62,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,32.7,,,fee schedule,,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,24.53,,,percent of total billed charges,,,32.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,22.96,,,percent of total billed charges,,
APIXABAN 2.5 MG TAB,2500007145,CDM,637,RC,3089331,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,32.7,32.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
APIXABAN 5 MG TAB,2500007146,CDM,637,RC,3089431,NDC,,,,,,inpatient,facility,5,UN,32.7,32.7,2.62,32.7,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.43,,,percent of total billed charges,,,,,,,,,32.7,,,percent of total billed charges,,,18.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,17.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.96,,,percent of total billed charges,,
APIXABAN 5 MG TAB,2500007146,CDM,637,RC,3089431,NDC,,,,,,outpatient,facility,5,UN,32.7,32.7,2.62,618.77,,19.1,,,percent of total billed charges,,,6.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,32.7,,,percent of total billed charges,,,28.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,28.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,28.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,29.43,,,percent of total billed charges,,,,,,,,,32.7,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.11,,,percent of total billed charges,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.05,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.85,,,percent of total billed charges,,,12.39,,,percent of total billed charges,,,16.94,,,percent of total billed charges,,,,,,,,,,,,,,,6.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,12.1,,,percent of total billed charges,,,12.1,,,percent of total billed charges,,,32.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.62,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,32.7,,,fee schedule,,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,24.53,,,percent of total billed charges,,,32.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,22.96,,,percent of total billed charges,,
APIXABAN 5 MG TAB,2500007146,CDM,637,RC,3089431,NDC,999,EAPG,,,,outpatient,facility,5,UN,32.7,32.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARTIFICIAL TEARS OP SOLN 15ML,2500007162,CDM,637,RC,1747806012,NDC,,,,,,inpatient,facility,15,UN,13.34,13.34,1.07,13.34,,,,,,,,,,,,,,13.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.01,,,percent of total billed charges,,,,,,,,,13.34,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.34,,,percent of total billed charges,,,,,,,,,,,,,,,13.34,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,13.34,,,percent of total billed charges,,,13.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.37,,,percent of total billed charges,,
ARTIFICIAL TEARS OP SOLN 15ML,2500007162,CDM,637,RC,1747806012,NDC,,,,,,outpatient,facility,15,UN,13.34,13.34,1.07,618.77,,7.79,,,percent of total billed charges,,,2.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.34,,,percent of total billed charges,,,11.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,11.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,11.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.01,,,percent of total billed charges,,,,,,,,,13.34,,,percent of total billed charges,,,9.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.25,,,percent of total billed charges,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,7.2,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,13.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,13.34,,,percent of total billed charges,,,13.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.14,,,percent of total billed charges,,,5.05,,,percent of total billed charges,,,6.91,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.94,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,13.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.07,,,percent of total billed charges,,,13.34,,,percent of total billed charges,,,13.34,,,percent of total billed charges,,,,,,,,,,,,,,,13.34,,,percent of total billed charges,,,13.34,,,percent of total billed charges,,,,,,,,,13.34,,,fee schedule,,,12.41,,,percent of total billed charges,,,,,,,,,,,,,,,12.41,,,percent of total billed charges,,,12.41,,,percent of total billed charges,,,12.41,,,percent of total billed charges,,,10,,,percent of total billed charges,,,13.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.34,,,percent of total billed charges,,,13.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.67,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.37,,,percent of total billed charges,,
ARTIFICIAL TEARS OP SOLN 15ML,2500007162,CDM,637,RC,1747806012,NDC,999,EAPG,,,,outpatient,facility,15,UN,13.34,13.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ASCORBIC ACID 500 MG TAB,2500007183,CDM,637,RC,904052361,NDC,,,,,,inpatient,facility,500,UN,1.47,1.47,0.12,1.47,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,1.47,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,
ASCORBIC ACID 500 MG TAB,2500007183,CDM,637,RC,904052361,NDC,,,,,,outpatient,facility,500,UN,1.47,1.47,0.12,618.77,,0.86,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.47,,,percent of total billed charges,,,1.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.32,,,percent of total billed charges,,,,,,,,,1.47,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.54,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,1.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,,,,,,,1.47,,,fee schedule,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,1.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.47,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.03,,,percent of total billed charges,,
ASCORBIC ACID 500 MG TAB,2500007183,CDM,637,RC,904052361,NDC,999,EAPG,,,,outpatient,facility,500,UN,1.47,1.47,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ASPIRIN 325 MG TAB,2500007194,CDM,637,RC,536105429,NDC,,,,,,inpatient,facility,325,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
ASPIRIN 325 MG TAB,2500007194,CDM,637,RC,536105429,NDC,,,,,,outpatient,facility,325,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
ASPIRIN 325 MG TAB,2500007194,CDM,637,RC,536105429,NDC,999,EAPG,,,,outpatient,facility,325,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ASPIRIN 325 MG TABEC,2500007195,CDM,637,RC,536123201,NDC,,,,,,inpatient,facility,325,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
ASPIRIN 325 MG TABEC,2500007195,CDM,637,RC,536123201,NDC,,,,,,outpatient,facility,325,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
ASPIRIN 325 MG TABEC,2500007195,CDM,637,RC,536123201,NDC,999,EAPG,,,,outpatient,facility,325,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ASPIRIN 300 MG SUPP,2500007197,CDM,637,RC,574703412,NDC,,,,,,inpatient,facility,300,UN,2.19,2.19,0.18,2.19,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,2.19,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,
ASPIRIN 300 MG SUPP,2500007197,CDM,637,RC,574703412,NDC,,,,,,outpatient,facility,300,UN,2.19,2.19,0.18,618.77,,1.28,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.19,,,percent of total billed charges,,,1.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.97,,,percent of total billed charges,,,,,,,,,2.19,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.81,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,2.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,2.19,,,fee schedule,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,2.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.19,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.54,,,percent of total billed charges,,
ASPIRIN 300 MG SUPP,2500007197,CDM,637,RC,574703412,NDC,999,EAPG,,,,outpatient,facility,300,UN,2.19,2.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ASPIRIN 81 MG CHEW TAB,2500007205,CDM,637,RC,904679480,NDC,,,,,,inpatient,facility,81,UN,1.88,1.88,0.15,1.88,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,
ASPIRIN 81 MG CHEW TAB,2500007205,CDM,637,RC,904679480,NDC,,,,,,outpatient,facility,81,UN,1.88,1.88,0.15,618.77,,1.1,,,percent of total billed charges,,,0.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.88,,,percent of total billed charges,,,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.69,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.7,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,1.88,,,fee schedule,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.32,,,percent of total billed charges,,
ASPIRIN 81 MG CHEW TAB,2500007205,CDM,637,RC,904679480,NDC,999,EAPG,,,,outpatient,facility,81,UN,1.88,1.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ASPIRIN 81 MG TABEC,2500007206,CDM,637,RC,536123441,NDC,,,,,,inpatient,facility,81,UN,1.94,1.94,0.16,1.94,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,
ASPIRIN 81 MG TABEC,2500007206,CDM,637,RC,536123441,NDC,,,,,,outpatient,facility,81,UN,1.94,1.94,0.16,618.77,,1.13,,,percent of total billed charges,,,0.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.94,,,percent of total billed charges,,,1.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.75,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.72,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,1.94,,,fee schedule,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,1.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.36,,,percent of total billed charges,,
ASPIRIN 81 MG TABEC,2500007206,CDM,637,RC,536123441,NDC,999,EAPG,,,,outpatient,facility,81,UN,1.94,1.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATENOLOL 50 MG TAB,2500007222,CDM,637,RC,5107968420,NDC,,,,,,inpatient,facility,50,UN,2.94,2.94,0.24,2.94,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,,,,,,,2.94,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,
ATENOLOL 50 MG TAB,2500007222,CDM,637,RC,5107968420,NDC,,,,,,outpatient,facility,50,UN,2.94,2.94,0.24,618.77,,1.72,,,percent of total billed charges,,,0.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.94,,,percent of total billed charges,,,2.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.65,,,percent of total billed charges,,,,,,,,,2.94,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,2.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,2.94,,,fee schedule,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.94,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.06,,,percent of total billed charges,,
ATENOLOL 50 MG TAB,2500007222,CDM,637,RC,5107968420,NDC,999,EAPG,,,,outpatient,facility,50,UN,2.94,2.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATENOLOL 25 MG TAB,2500007224,CDM,637,RC,6586216899,NDC,,,,,,inpatient,facility,25,UN,2.7,2.7,0.22,2.7,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,,,,,,,2.7,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,
ATENOLOL 25 MG TAB,2500007224,CDM,637,RC,6586216899,NDC,,,,,,outpatient,facility,25,UN,2.7,2.7,0.22,618.77,,1.58,,,percent of total billed charges,,,0.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.7,,,percent of total billed charges,,,2.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.43,,,percent of total billed charges,,,,,,,,,2.7,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.46,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1,,,percent of total billed charges,,,1,,,percent of total billed charges,,,2.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.22,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,2.7,,,fee schedule,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,2.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.7,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.9,,,percent of total billed charges,,
ATENOLOL 25 MG TAB,2500007224,CDM,637,RC,6586216899,NDC,999,EAPG,,,,outpatient,facility,25,UN,2.7,2.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATORVASTATIN 10 MG TAB,2500007230,CDM,637,RC,6050525788,NDC,,,,,,inpatient,facility,10,UN,13.37,13.37,1.07,13.37,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.03,,,percent of total billed charges,,,,,,,,,13.37,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,6.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.39,,,percent of total billed charges,,
ATORVASTATIN 10 MG TAB,2500007230,CDM,637,RC,6050525788,NDC,,,,,,outpatient,facility,10,UN,13.37,13.37,1.07,618.77,,7.81,,,percent of total billed charges,,,2.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.37,,,percent of total billed charges,,,11.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,11.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,11.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.03,,,percent of total billed charges,,,,,,,,,13.37,,,percent of total billed charges,,,9.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.27,,,percent of total billed charges,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.97,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.16,,,percent of total billed charges,,,5.06,,,percent of total billed charges,,,6.92,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,13.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.07,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,,,,,,,13.37,,,fee schedule,,,12.44,,,percent of total billed charges,,,,,,,,,,,,,,,12.44,,,percent of total billed charges,,,12.44,,,percent of total billed charges,,,12.44,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,13.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.37,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.39,,,percent of total billed charges,,
ATORVASTATIN 10 MG TAB,2500007230,CDM,637,RC,6050525788,NDC,999,EAPG,,,,outpatient,facility,10,UN,13.37,13.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATORVASTATIN 20 MG TAB,2500007232,CDM,637,RC,6050525798,NDC,,,,,,inpatient,facility,20,UN,19.04,19.04,1.52,19.04,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.14,,,percent of total billed charges,,,,,,,,,19.04,,,percent of total billed charges,,,10.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,
ATORVASTATIN 20 MG TAB,2500007232,CDM,637,RC,6050525798,NDC,,,,,,outpatient,facility,20,UN,19.04,19.04,1.52,618.77,,11.12,,,percent of total billed charges,,,3.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,19.04,,,percent of total billed charges,,,16.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,16.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,16.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,17.14,,,percent of total billed charges,,,,,,,,,19.04,,,percent of total billed charges,,,12.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.62,,,percent of total billed charges,,,,,,,,,,,,,,,10.28,,,percent of total billed charges,,,10.28,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.47,,,percent of total billed charges,,,7.21,,,percent of total billed charges,,,9.86,,,percent of total billed charges,,,,,,,,,,,,,,,3.81,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.04,,,percent of total billed charges,,,7.04,,,percent of total billed charges,,,19.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.52,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,,,,,,,19.04,,,fee schedule,,,17.71,,,percent of total billed charges,,,,,,,,,,,,,,,17.71,,,percent of total billed charges,,,17.71,,,percent of total billed charges,,,17.71,,,percent of total billed charges,,,14.28,,,percent of total billed charges,,,19.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,19.04,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,13.37,,,percent of total billed charges,,
ATORVASTATIN 20 MG TAB,2500007232,CDM,637,RC,6050525798,NDC,999,EAPG,,,,outpatient,facility,20,UN,19.04,19.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATORVASTATIN 40 MG TAB,2500007234,CDM,637,RC,904629261,NDC,,,,,,inpatient,facility,40,UN,1.05,1.05,0.08,1.05,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,1.05,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,
ATORVASTATIN 40 MG TAB,2500007234,CDM,637,RC,904629261,NDC,,,,,,outpatient,facility,40,UN,1.05,1.05,0.08,618.77,,0.61,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.05,,,percent of total billed charges,,,0.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.95,,,percent of total billed charges,,,,,,,,,1.05,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,1.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,1.05,,,fee schedule,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,1.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.74,,,percent of total billed charges,,
ATORVASTATIN 40 MG TAB,2500007234,CDM,637,RC,904629261,NDC,999,EAPG,,,,outpatient,facility,40,UN,1.05,1.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATOVAQUONE 750 MG/5 ML,2500007245,CDM,637,RC,904706453,NDC,,,,,,inpatient,facility,5,UN,53.26,53.26,4.26,53.26,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.93,,,percent of total billed charges,,,,,,,,,53.26,,,percent of total billed charges,,,29.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,27.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.4,,,percent of total billed charges,,
ATOVAQUONE 750 MG/5 ML,2500007245,CDM,637,RC,904706453,NDC,,,,,,outpatient,facility,5,UN,53.26,53.26,4.26,618.77,,31.1,,,percent of total billed charges,,,10.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,53.26,,,percent of total billed charges,,,46.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,46.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,46.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,19.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,47.93,,,percent of total billed charges,,,,,,,,,53.26,,,percent of total billed charges,,,36.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.9,,,percent of total billed charges,,,,,,,,,,,,,,,28.76,,,percent of total billed charges,,,28.76,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.77,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.48,,,percent of total billed charges,,,20.17,,,percent of total billed charges,,,27.58,,,percent of total billed charges,,,,,,,,,,,,,,,10.65,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,19.71,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,53.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.26,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,,,,,,,53.26,,,fee schedule,,,49.54,,,percent of total billed charges,,,,,,,,,,,,,,,49.54,,,percent of total billed charges,,,49.54,,,percent of total billed charges,,,49.54,,,percent of total billed charges,,,39.95,,,percent of total billed charges,,,53.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,53.26,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,37.4,,,percent of total billed charges,,
ATOVAQUONE 750 MG/5 ML,2500007245,CDM,637,RC,904706453,NDC,999,EAPG,,,,outpatient,facility,5,UN,53.26,53.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATROPINE SULF 1  OP SOLN 5 ML,2500007264,CDM,637,RC,65030355,NDC,,,,,,inpatient,facility,5,UN,267.7,267.7,21.42,267.7,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.93,,,percent of total billed charges,,,,,,,,,267.7,,,percent of total billed charges,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,139.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.42,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.98,,,percent of total billed charges,,
ATROPINE SULF 1  OP SOLN 5 ML,2500007264,CDM,637,RC,65030355,NDC,,,,,,outpatient,facility,5,UN,267.7,267.7,21.42,618.77,,156.34,,,percent of total billed charges,,,52.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,267.7,,,percent of total billed charges,,,235.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,235.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,235.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,97.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,240.93,,,percent of total billed charges,,,,,,,,,267.7,,,percent of total billed charges,,,181.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.59,,,percent of total billed charges,,,,,,,,,,,,,,,144.56,,,percent of total billed charges,,,144.56,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,139.58,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,203.45,,,percent of total billed charges,,,101.4,,,percent of total billed charges,,,138.64,,,percent of total billed charges,,,,,,,,,,,,,,,53.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,99.05,,,percent of total billed charges,,,99.05,,,percent of total billed charges,,,267.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,267.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.42,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,,,,,,,267.7,,,fee schedule,,,249.01,,,percent of total billed charges,,,,,,,,,,,,,,,249.01,,,percent of total billed charges,,,249.01,,,percent of total billed charges,,,249.01,,,percent of total billed charges,,,200.77,,,percent of total billed charges,,,267.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,267.7,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,187.98,,,percent of total billed charges,,
ATROPINE SULF 1  OP SOLN 5 ML,2500007264,CDM,637,RC,65030355,NDC,999,EAPG,,,,outpatient,facility,5,UN,267.7,267.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATROPINE SULF 1  OP 2 ML DRPET,2500007265,CDM,637,RC,1747821502,NDC,,,,,,inpatient,facility,2,UN,157.94,157.94,12.64,157.94,,,,,,,,,,,,,,157.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.15,,,percent of total billed charges,,,,,,,,,157.94,,,percent of total billed charges,,,87.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.94,,,percent of total billed charges,,,,,,,,,,,,,,,157.94,,,percent of total billed charges,,,82.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.64,,,percent of total billed charges,,,157.94,,,percent of total billed charges,,,157.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,157.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.91,,,percent of total billed charges,,
ATROPINE SULF 1  OP 2 ML DRPET,2500007265,CDM,637,RC,1747821502,NDC,,,,,,outpatient,facility,2,UN,157.94,157.94,12.64,618.77,,92.24,,,percent of total billed charges,,,30.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,157.94,,,percent of total billed charges,,,139.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,139.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,139.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,157.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,57.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,142.15,,,percent of total billed charges,,,,,,,,,157.94,,,percent of total billed charges,,,106.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.3,,,percent of total billed charges,,,,,,,,,,,,,,,85.29,,,percent of total billed charges,,,85.29,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,157.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.35,,,percent of total billed charges,,,157.94,,,percent of total billed charges,,,157.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.03,,,percent of total billed charges,,,59.83,,,percent of total billed charges,,,81.8,,,percent of total billed charges,,,,,,,,,,,,,,,31.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,58.44,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,157.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,157.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.64,,,percent of total billed charges,,,157.94,,,percent of total billed charges,,,157.94,,,percent of total billed charges,,,,,,,,,,,,,,,157.94,,,percent of total billed charges,,,157.94,,,percent of total billed charges,,,,,,,,,157.94,,,fee schedule,,,146.92,,,percent of total billed charges,,,,,,,,,,,,,,,146.92,,,percent of total billed charges,,,146.92,,,percent of total billed charges,,,146.92,,,percent of total billed charges,,,118.45,,,percent of total billed charges,,,157.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,157.94,,,percent of total billed charges,,,157.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,110.91,,,percent of total billed charges,,
ATROPINE SULF 1  OP 2 ML DRPET,2500007265,CDM,637,RC,1747821502,NDC,999,EAPG,,,,outpatient,facility,2,UN,157.94,157.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATROPINE SULF INJ 0.4 MG,2500007277,CDM,636,RC,J0461,HCPCS,517040125,NDC,,,,inpatient,facility,1,UN,26.4,26.4,2.11,26.4,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,26.4,,,percent of total billed charges,,,14.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,26.4,,,percent of total billed charges,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.54,,,percent of total billed charges,,
ATROPINE SULF INJ 0.4 MG,2500007277,CDM,636,RC,J0461,HCPCS,517040125,NDC,,,,outpatient,facility,1,UN,26.4,26.4,0.09,618.77,,15.42,,,percent of total billed charges,,,5.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,26.4,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,23.76,,,percent of total billed charges,,,,,,,,,26.4,,,percent of total billed charges,,,17.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,26.4,,,percent of total billed charges,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.06,,,percent of total billed charges,,,10,,,percent of total billed charges,,,13.67,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,26.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.11,,,percent of total billed charges,,,26.4,,,percent of total billed charges,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,26.4,,,percent of total billed charges,,,,,,,,,26.4,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,26.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,26.4,,,percent of total billed charges,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,18.54,,,percent of total billed charges,,
ATROPINE SULF INJ 0.4 MG,2500007277,CDM,636,RC,J0461,HCPCS,517040125,NDC,496,EAPG,,outpatient,facility,1,UN,26.4,26.4,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AZELASTINE 137MCG SPRAY,2500007310,CDM,637,RC,5199181403,NDC,,,,,,inpatient,facility,30,UN,347.16,347.16,27.77,347.16,,,,,,,,,,,,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312.44,,,percent of total billed charges,,,,,,,,,347.16,,,percent of total billed charges,,,192.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,347.16,,,percent of total billed charges,,,181.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.77,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.78,,,percent of total billed charges,,
AZELASTINE 137MCG SPRAY,2500007310,CDM,637,RC,5199181403,NDC,,,,,,outpatient,facility,30,UN,347.16,347.16,27.77,618.77,,202.74,,,percent of total billed charges,,,67.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,347.16,,,percent of total billed charges,,,305.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,305.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,305.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,127.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,312.44,,,percent of total billed charges,,,,,,,,,347.16,,,percent of total billed charges,,,235.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.62,,,percent of total billed charges,,,,,,,,,,,,,,,187.47,,,percent of total billed charges,,,187.47,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,181.01,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.84,,,percent of total billed charges,,,131.5,,,percent of total billed charges,,,179.79,,,percent of total billed charges,,,,,,,,,,,,,,,69.43,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,128.45,,,percent of total billed charges,,,128.45,,,percent of total billed charges,,,347.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,347.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.77,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,347.16,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,,,,,,,347.16,,,fee schedule,,,322.93,,,percent of total billed charges,,,,,,,,,,,,,,,322.93,,,percent of total billed charges,,,322.93,,,percent of total billed charges,,,322.93,,,percent of total billed charges,,,260.37,,,percent of total billed charges,,,347.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,347.16,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,243.78,,,percent of total billed charges,,
AZELASTINE 137MCG SPRAY,2500007310,CDM,637,RC,5199181403,NDC,999,EAPG,,,,outpatient,facility,30,UN,347.16,347.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AZITHROMYCIN 250 MG TAB,2500007320,CDM,637,RC,Q0144,HCPCS,5976221981,NDC,,,,inpatient,facility,250,UN,4.09,4.09,0.33,4.09,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,,,,,,,4.09,,,percent of total billed charges,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,
AZITHROMYCIN 250 MG TAB,2500007320,CDM,637,RC,Q0144,HCPCS,5976221981,NDC,,,,outpatient,facility,250,UN,4.09,4.09,0.33,618.77,,2.39,,,percent of total billed charges,,,0.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.09,,,percent of total billed charges,,,32.71,,,fee schedule,,,31.52,,,fee schedule,,,,,,,,,31.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.68,,,percent of total billed charges,,,,,,,,,4.09,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,fee schedule,,,4.09,,,fee schedule,,,,,,,,,618.77,,,per diem,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.11,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.09,,,fee schedule,,,4.09,,,fee schedule,,,4.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.33,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,4.09,,,fee schedule,,,4.09,,,fee schedule,,,,,,,,,,,,,,,4.09,,,fee schedule,,,4.09,,,fee schedule,,,4.09,,,fee schedule,,,4.09,,,fee schedule,,,4.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.87,,,percent of total billed charges,,
AZITHROMYCIN 250 MG TAB,2500007320,CDM,637,RC,Q0144,HCPCS,5976221981,NDC,999,EAPG,,outpatient,facility,250,UN,4.09,4.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BACITRACIN OINT 0.9 GM PKT,2500007333,CDM,637,RC,5332908986,NDC,,,,,,inpatient,facility,0.9,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
BACITRACIN OINT 0.9 GM PKT,2500007333,CDM,637,RC,5332908986,NDC,,,,,,outpatient,facility,0.9,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
BACITRACIN OINT 0.9 GM PKT,2500007333,CDM,637,RC,5332908986,NDC,999,EAPG,,,,outpatient,facility,0.9,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BACITRACIN OINT 500 U/GM 30 GM,2500007336,CDM,637,RC,713028031,NDC,,,,,,inpatient,facility,30,UN,5.51,5.51,0.44,5.51,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,,,,,,,,5.51,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,
BACITRACIN OINT 500 U/GM 30 GM,2500007336,CDM,637,RC,713028031,NDC,,,,,,outpatient,facility,30,UN,5.51,5.51,0.44,618.77,,3.22,,,percent of total billed charges,,,1.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.51,,,percent of total billed charges,,,4.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.96,,,percent of total billed charges,,,,,,,,,5.51,,,percent of total billed charges,,,3.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.23,,,percent of total billed charges,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,2.09,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,5.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.44,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,5.51,,,fee schedule,,,5.13,,,percent of total billed charges,,,,,,,,,,,,,,,5.13,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.87,,,percent of total billed charges,,
BACITRACIN OINT 500 U/GM 30 GM,2500007336,CDM,637,RC,713028031,NDC,999,EAPG,,,,outpatient,facility,30,UN,5.51,5.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BACLOFEN 10 MG TAB,2500007350,CDM,637,RC,904647561,NDC,,,,,,inpatient,facility,10,UN,1.38,1.38,0.11,1.38,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,,,,,,,1.38,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,
BACLOFEN 10 MG TAB,2500007350,CDM,637,RC,904647561,NDC,,,,,,outpatient,facility,10,UN,1.38,1.38,0.11,618.77,,0.81,,,percent of total billed charges,,,0.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.38,,,percent of total billed charges,,,1.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.24,,,percent of total billed charges,,,,,,,,,1.38,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.51,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,1.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,1.38,,,fee schedule,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,1.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.97,,,percent of total billed charges,,
BACLOFEN 10 MG TAB,2500007350,CDM,637,RC,904647561,NDC,999,EAPG,,,,outpatient,facility,10,UN,1.38,1.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BELLADONNA/PHENOBARB 5 ML UDC,2500007410,CDM,637,RC,6668906310,NDC,,,,,,inpatient,facility,5,UN,187.11,187.11,14.97,187.11,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.4,,,percent of total billed charges,,,,,,,,,187.11,,,percent of total billed charges,,,103.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,97.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.97,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.39,,,percent of total billed charges,,
BELLADONNA/PHENOBARB 5 ML UDC,2500007410,CDM,637,RC,6668906310,NDC,,,,,,outpatient,facility,5,UN,187.11,187.11,14.97,618.77,,109.27,,,percent of total billed charges,,,36.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,187.11,,,percent of total billed charges,,,164.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,164.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,164.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,68.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,168.4,,,percent of total billed charges,,,,,,,,,187.11,,,percent of total billed charges,,,126.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.7,,,percent of total billed charges,,,,,,,,,,,,,,,101.04,,,percent of total billed charges,,,101.04,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,97.56,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.2,,,percent of total billed charges,,,70.88,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,37.42,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,69.23,,,percent of total billed charges,,,69.23,,,percent of total billed charges,,,187.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,187.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.97,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,,,,,,,187.11,,,fee schedule,,,174.05,,,percent of total billed charges,,,,,,,,,,,,,,,174.05,,,percent of total billed charges,,,174.05,,,percent of total billed charges,,,174.05,,,percent of total billed charges,,,140.33,,,percent of total billed charges,,,187.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,187.11,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,131.39,,,percent of total billed charges,,
BELLADONNA/PHENOBARB 5 ML UDC,2500007410,CDM,637,RC,6668906310,NDC,999,EAPG,,,,outpatient,facility,5,UN,187.11,187.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZOCAINE 20  AER SPR 60 GM,2500007463,CDM,637,RC,283067902,NDC,,,,,,inpatient,facility,56,UN,62.34,62.34,4.99,62.34,,,,,,,,,,,,,,62.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.11,,,percent of total billed charges,,,,,,,,,62.34,,,percent of total billed charges,,,34.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.34,,,percent of total billed charges,,,,,,,,,,,,,,,62.34,,,percent of total billed charges,,,32.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.99,,,percent of total billed charges,,,62.34,,,percent of total billed charges,,,62.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.78,,,percent of total billed charges,,
BENZOCAINE 20  AER SPR 60 GM,2500007463,CDM,637,RC,283067902,NDC,,,,,,outpatient,facility,56,UN,62.34,62.34,4.99,618.77,,36.41,,,percent of total billed charges,,,12.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,62.34,,,percent of total billed charges,,,54.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,54.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,54.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,62.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,22.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,56.11,,,percent of total billed charges,,,,,,,,,62.34,,,percent of total billed charges,,,42.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.88,,,percent of total billed charges,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,62.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.5,,,percent of total billed charges,,,62.34,,,percent of total billed charges,,,62.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.38,,,percent of total billed charges,,,23.61,,,percent of total billed charges,,,32.29,,,percent of total billed charges,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,23.07,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,62.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,62.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.99,,,percent of total billed charges,,,62.34,,,percent of total billed charges,,,62.34,,,percent of total billed charges,,,,,,,,,,,,,,,62.34,,,percent of total billed charges,,,62.34,,,percent of total billed charges,,,,,,,,,62.34,,,fee schedule,,,57.99,,,percent of total billed charges,,,,,,,,,,,,,,,57.99,,,percent of total billed charges,,,57.99,,,percent of total billed charges,,,57.99,,,percent of total billed charges,,,46.76,,,percent of total billed charges,,,62.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,62.34,,,percent of total billed charges,,,62.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,43.78,,,percent of total billed charges,,
BENZOCAINE 20  AER SPR 60 GM,2500007463,CDM,637,RC,283067902,NDC,999,EAPG,,,,outpatient,facility,56,UN,62.34,62.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZOCAINE 20  SPR 0.5 ML,2500007466,CDM,637,RC,283061026,NDC,,,,,,inpatient,facility,1,UN,19.95,19.95,1.6,19.95,,,,,,,,,,,,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.95,,,percent of total billed charges,,,,,,,,,19.95,,,percent of total billed charges,,,11.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,19.95,,,percent of total billed charges,,,10.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.01,,,percent of total billed charges,,
BENZOCAINE 20  SPR 0.5 ML,2500007466,CDM,637,RC,283061026,NDC,,,,,,outpatient,facility,1,UN,19.95,19.95,1.6,618.77,,11.65,,,percent of total billed charges,,,3.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,19.95,,,percent of total billed charges,,,17.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,17.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,17.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,17.95,,,percent of total billed charges,,,,,,,,,19.95,,,percent of total billed charges,,,13.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.32,,,percent of total billed charges,,,,,,,,,,,,,,,10.77,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.4,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.16,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,10.33,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.38,,,percent of total billed charges,,,7.38,,,percent of total billed charges,,,19.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.6,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,19.95,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,19.95,,,fee schedule,,,18.56,,,percent of total billed charges,,,,,,,,,,,,,,,18.56,,,percent of total billed charges,,,18.56,,,percent of total billed charges,,,18.56,,,percent of total billed charges,,,14.96,,,percent of total billed charges,,,19.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,19.95,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,14.01,,,percent of total billed charges,,
BENZOCAINE 20  SPR 0.5 ML,2500007466,CDM,637,RC,283061026,NDC,999,EAPG,,,,outpatient,facility,1,UN,19.95,19.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZONATATE 100 MG CAP,2500007510,CDM,637,RC,904656461,NDC,,,,,,inpatient,facility,100,UN,1.61,1.61,0.13,1.61,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,
BENZONATATE 100 MG CAP,2500007510,CDM,637,RC,904656461,NDC,,,,,,outpatient,facility,100,UN,1.61,1.61,0.13,618.77,,0.94,,,percent of total billed charges,,,0.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.61,,,percent of total billed charges,,,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.45,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.6,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,1.61,,,fee schedule,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,1.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.13,,,percent of total billed charges,,
BENZONATATE 100 MG CAP,2500007510,CDM,637,RC,904656461,NDC,999,EAPG,,,,outpatient,facility,100,UN,1.61,1.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZTROPINE MESY 0.5 MG TAB,2500007530,CDM,637,RC,904678861,NDC,,,,,,inpatient,facility,0.5,UN,1.45,1.45,0.12,1.45,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,
BENZTROPINE MESY 0.5 MG TAB,2500007530,CDM,637,RC,904678861,NDC,,,,,,outpatient,facility,0.5,UN,1.45,1.45,0.12,618.77,,0.85,,,percent of total billed charges,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.45,,,percent of total billed charges,,,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.3,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.54,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,1.45,,,fee schedule,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.02,,,percent of total billed charges,,
BENZTROPINE MESY 0.5 MG TAB,2500007530,CDM,637,RC,904678861,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,1.45,1.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZTROPINE MESY 1 MG TAB,2500007532,CDM,637,RC,904679061,NDC,,,,,,inpatient,facility,1,UN,1.61,1.61,0.13,1.61,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,
BENZTROPINE MESY 1 MG TAB,2500007532,CDM,637,RC,904679061,NDC,,,,,,outpatient,facility,1,UN,1.61,1.61,0.13,618.77,,0.94,,,percent of total billed charges,,,0.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.61,,,percent of total billed charges,,,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.45,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.6,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,1.61,,,fee schedule,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,1.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.13,,,percent of total billed charges,,
BENZTROPINE MESY 1 MG TAB,2500007532,CDM,637,RC,904679061,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.61,1.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BETAMETH DIP 0.05  OINT 15 GM,2500007577,CDM,637,RC,168005615,NDC,,,,,,inpatient,facility,15,UN,202.92,202.92,16.23,202.92,,,,,,,,,,,,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.63,,,percent of total billed charges,,,,,,,,,202.92,,,percent of total billed charges,,,112.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,202.92,,,percent of total billed charges,,,105.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.23,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.49,,,percent of total billed charges,,
BETAMETH DIP 0.05  OINT 15 GM,2500007577,CDM,637,RC,168005615,NDC,,,,,,outpatient,facility,15,UN,202.92,202.92,16.23,618.77,,118.51,,,percent of total billed charges,,,39.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,202.92,,,percent of total billed charges,,,178.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,178.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,178.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,74.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,182.63,,,percent of total billed charges,,,,,,,,,202.92,,,percent of total billed charges,,,137.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.84,,,percent of total billed charges,,,,,,,,,,,,,,,109.58,,,percent of total billed charges,,,109.58,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,105.8,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.22,,,percent of total billed charges,,,76.87,,,percent of total billed charges,,,105.09,,,percent of total billed charges,,,,,,,,,,,,,,,40.58,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,75.08,,,percent of total billed charges,,,75.08,,,percent of total billed charges,,,202.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,202.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.23,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,202.92,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,,,,,,,202.92,,,fee schedule,,,188.76,,,percent of total billed charges,,,,,,,,,,,,,,,188.76,,,percent of total billed charges,,,188.76,,,percent of total billed charges,,,188.76,,,percent of total billed charges,,,152.19,,,percent of total billed charges,,,202.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,202.92,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,142.49,,,percent of total billed charges,,
BETAMETH DIP 0.05  OINT 15 GM,2500007577,CDM,637,RC,168005615,NDC,999,EAPG,,,,outpatient,facility,15,UN,202.92,202.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BETAMETH DIP AUG 0.05  OINT15G,2500007584,CDM,637,RC,168026850,NDC,,,,,,inpatient,facility,15,UN,184.24,184.24,14.74,184.24,,,,,,,,,,,,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.82,,,percent of total billed charges,,,,,,,,,184.24,,,percent of total billed charges,,,102,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,184.24,,,percent of total billed charges,,,96.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.74,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.37,,,percent of total billed charges,,
BETAMETH DIP AUG 0.05  OINT15G,2500007584,CDM,637,RC,168026850,NDC,,,,,,outpatient,facility,15,UN,184.24,184.24,14.74,618.77,,107.6,,,percent of total billed charges,,,35.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,184.24,,,percent of total billed charges,,,162.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,162.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,162.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,67.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,165.82,,,percent of total billed charges,,,,,,,,,184.24,,,percent of total billed charges,,,124.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.5,,,percent of total billed charges,,,,,,,,,,,,,,,99.49,,,percent of total billed charges,,,99.49,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.06,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.02,,,percent of total billed charges,,,69.79,,,percent of total billed charges,,,95.42,,,percent of total billed charges,,,,,,,,,,,,,,,36.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,68.17,,,percent of total billed charges,,,68.17,,,percent of total billed charges,,,184.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,184.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.74,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,184.24,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,,,,,,,184.24,,,fee schedule,,,171.38,,,percent of total billed charges,,,,,,,,,,,,,,,171.38,,,percent of total billed charges,,,171.38,,,percent of total billed charges,,,171.38,,,percent of total billed charges,,,138.18,,,percent of total billed charges,,,184.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,184.24,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,129.37,,,percent of total billed charges,,
BETAMETH DIP AUG 0.05  OINT15G,2500007584,CDM,637,RC,168026850,NDC,999,EAPG,,,,outpatient,facility,15,UN,184.24,184.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BETHANECHOL CHL 10 MG TAB,2500007620,CDM,637,RC,832051101,NDC,,,,,,inpatient,facility,10,UN,6.6,6.6,0.53,6.6,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,3.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,
BETHANECHOL CHL 10 MG TAB,2500007620,CDM,637,RC,832051101,NDC,,,,,,outpatient,facility,10,UN,6.6,6.6,0.53,618.77,,3.85,,,percent of total billed charges,,,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.6,,,percent of total billed charges,,,5.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.94,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,4.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,3.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.44,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,6.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.53,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,6.6,,,fee schedule,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,6.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.63,,,percent of total billed charges,,
BETHANECHOL CHL 10 MG TAB,2500007620,CDM,637,RC,832051101,NDC,999,EAPG,,,,outpatient,facility,10,UN,6.6,6.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BETHANECHOL CHL 25 MG TAB,2500007622,CDM,637,RC,832051201,NDC,,,,,,inpatient,facility,25,UN,8.81,8.81,0.7,8.81,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.93,,,percent of total billed charges,,,,,,,,,8.81,,,percent of total billed charges,,,4.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,
BETHANECHOL CHL 25 MG TAB,2500007622,CDM,637,RC,832051201,NDC,,,,,,outpatient,facility,25,UN,8.81,8.81,0.7,618.77,,5.15,,,percent of total billed charges,,,1.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.81,,,percent of total billed charges,,,7.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.93,,,percent of total billed charges,,,,,,,,,8.81,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.77,,,percent of total billed charges,,,,,,,,,,,,,,,4.76,,,percent of total billed charges,,,4.76,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,3.34,,,percent of total billed charges,,,4.56,,,percent of total billed charges,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,8.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.7,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,8.81,,,fee schedule,,,8.2,,,percent of total billed charges,,,,,,,,,,,,,,,8.2,,,percent of total billed charges,,,8.2,,,percent of total billed charges,,,8.2,,,percent of total billed charges,,,6.61,,,percent of total billed charges,,,8.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.19,,,percent of total billed charges,,
BETHANECHOL CHL 25 MG TAB,2500007622,CDM,637,RC,832051201,NDC,999,EAPG,,,,outpatient,facility,25,UN,8.81,8.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BICALUTAMIDE 50 MG TAB,2500007630,CDM,637,RC,4733548583,NDC,,,,,,inpatient,facility,50,UN,61.15,61.15,4.89,61.15,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.03,,,percent of total billed charges,,,,,,,,,61.15,,,percent of total billed charges,,,33.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,31.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.94,,,percent of total billed charges,,
BICALUTAMIDE 50 MG TAB,2500007630,CDM,637,RC,4733548583,NDC,,,,,,outpatient,facility,50,UN,61.15,61.15,4.89,618.77,,35.71,,,percent of total billed charges,,,11.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,61.15,,,percent of total billed charges,,,53.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,53.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,53.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,22.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,55.03,,,percent of total billed charges,,,,,,,,,61.15,,,percent of total billed charges,,,41.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.96,,,percent of total billed charges,,,,,,,,,,,,,,,33.02,,,percent of total billed charges,,,33.02,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.88,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.47,,,percent of total billed charges,,,23.16,,,percent of total billed charges,,,31.67,,,percent of total billed charges,,,,,,,,,,,,,,,12.23,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,22.63,,,percent of total billed charges,,,22.63,,,percent of total billed charges,,,61.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,61.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.89,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,,,,,,,61.15,,,fee schedule,,,56.88,,,percent of total billed charges,,,,,,,,,,,,,,,56.88,,,percent of total billed charges,,,56.88,,,percent of total billed charges,,,56.88,,,percent of total billed charges,,,45.86,,,percent of total billed charges,,,61.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,61.15,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,42.94,,,percent of total billed charges,,
BICALUTAMIDE 50 MG TAB,2500007630,CDM,637,RC,4733548583,NDC,999,EAPG,,,,outpatient,facility,50,UN,61.15,61.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BISACODYL 10 MG SUPP,2500007660,CDM,637,RC,574705050,NDC,,,,,,inpatient,facility,10,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
BISACODYL 10 MG SUPP,2500007660,CDM,637,RC,574705050,NDC,,,,,,outpatient,facility,10,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
BISACODYL 10 MG SUPP,2500007660,CDM,637,RC,574705050,NDC,999,EAPG,,,,outpatient,facility,10,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BISACODYL 5 MG TABEC,2500007663,CDM,637,RC,904640761,NDC,,,,,,inpatient,facility,5,UN,1.84,1.84,0.15,1.84,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,1.84,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,
BISACODYL 5 MG TABEC,2500007663,CDM,637,RC,904640761,NDC,,,,,,outpatient,facility,5,UN,1.84,1.84,0.15,618.77,,1.07,,,percent of total billed charges,,,0.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.84,,,percent of total billed charges,,,1.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.66,,,percent of total billed charges,,,,,,,,,1.84,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,1.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,1.84,,,fee schedule,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,1.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.29,,,percent of total billed charges,,
BISACODYL 5 MG TABEC,2500007663,CDM,637,RC,904640761,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.84,1.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BISMUTH SUBSALICYLATE 30ML UDC,2500007678,CDM,637,RC,3700003204,NDC,,,,,,inpatient,facility,30,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
BISMUTH SUBSALICYLATE 30ML UDC,2500007678,CDM,637,RC,3700003204,NDC,,,,,,outpatient,facility,30,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
BISMUTH SUBSALICYLATE 30ML UDC,2500007678,CDM,637,RC,3700003204,NDC,999,EAPG,,,,outpatient,facility,30,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BRIMONIDINE TART OPH 0.2  5 ML,2500007740,CDM,637,RC,6131414305,NDC,,,,,,inpatient,facility,5,UN,107.75,107.75,8.62,107.75,,,,,,,,,,,,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.98,,,percent of total billed charges,,,,,,,,,107.75,,,percent of total billed charges,,,59.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,107.75,,,percent of total billed charges,,,56.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.62,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.66,,,percent of total billed charges,,
BRIMONIDINE TART OPH 0.2  5 ML,2500007740,CDM,637,RC,6131414305,NDC,,,,,,outpatient,facility,5,UN,107.75,107.75,8.62,618.77,,62.93,,,percent of total billed charges,,,21.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,107.75,,,percent of total billed charges,,,94.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,94.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,94.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,39.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,96.98,,,percent of total billed charges,,,,,,,,,107.75,,,percent of total billed charges,,,72.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.75,,,percent of total billed charges,,,,,,,,,,,,,,,58.19,,,percent of total billed charges,,,58.19,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.18,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.89,,,percent of total billed charges,,,40.82,,,percent of total billed charges,,,55.8,,,percent of total billed charges,,,,,,,,,,,,,,,21.55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,39.87,,,percent of total billed charges,,,39.87,,,percent of total billed charges,,,107.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,107.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.62,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,107.75,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,,,,,,,107.75,,,fee schedule,,,100.23,,,percent of total billed charges,,,,,,,,,,,,,,,100.23,,,percent of total billed charges,,,100.23,,,percent of total billed charges,,,100.23,,,percent of total billed charges,,,80.81,,,percent of total billed charges,,,107.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,107.75,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,75.66,,,percent of total billed charges,,
BRIMONIDINE TART OPH 0.2  5 ML,2500007740,CDM,637,RC,6131414305,NDC,999,EAPG,,,,outpatient,facility,5,UN,107.75,107.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BRIMONIDINE 0.1  OPH 5 ML,2500007745,CDM,637,RC,6131414310,NDC,,,,,,inpatient,facility,10,UN,641.65,641.65,51.33,641.65,,,,,,,,,,,,,,641.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.49,,,percent of total billed charges,,,,,,,,,641.65,,,percent of total billed charges,,,355.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,585.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.65,,,percent of total billed charges,,,,,,,,,,,,,,,641.65,,,percent of total billed charges,,,334.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,641.65,,,percent of total billed charges,,,641.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,641.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,450.57,,,percent of total billed charges,,
BRIMONIDINE 0.1  OPH 5 ML,2500007745,CDM,637,RC,6131414310,NDC,,,,,,outpatient,facility,10,UN,641.65,641.65,51.33,641.65,,374.72,,,percent of total billed charges,,,125.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,641.65,,,percent of total billed charges,,,564.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,564.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,564.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,641.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,234.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,577.49,,,percent of total billed charges,,,,,,,,,641.65,,,percent of total billed charges,,,434.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.79,,,percent of total billed charges,,,,,,,,,,,,,,,346.49,,,percent of total billed charges,,,346.49,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,641.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,334.56,,,percent of total billed charges,,,641.65,,,percent of total billed charges,,,641.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.65,,,percent of total billed charges,,,243.06,,,percent of total billed charges,,,332.31,,,percent of total billed charges,,,,,,,,,,,,,,,128.33,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,237.41,,,percent of total billed charges,,,237.41,,,percent of total billed charges,,,641.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,641.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.33,,,percent of total billed charges,,,641.65,,,percent of total billed charges,,,641.65,,,percent of total billed charges,,,,,,,,,,,,,,,641.65,,,percent of total billed charges,,,641.65,,,percent of total billed charges,,,,,,,,,641.65,,,fee schedule,,,596.86,,,percent of total billed charges,,,,,,,,,,,,,,,596.86,,,percent of total billed charges,,,596.86,,,percent of total billed charges,,,596.86,,,percent of total billed charges,,,481.24,,,percent of total billed charges,,,641.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,641.65,,,percent of total billed charges,,,641.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,450.57,,,percent of total billed charges,,
BRIMONIDINE 0.1  OPH 5 ML,2500007745,CDM,637,RC,6131414310,NDC,999,EAPG,,,,outpatient,facility,10,UN,641.65,641.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUDESONIDE 0.5 MG/2 ML NEB SOL,2500007785,CDM,637,RC,J7626,HCPCS,93681655,NDC,,,,inpatient,facility,2,UN,36.56,36.56,2.92,36.56,,,,,,,,,,,,,,36.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.9,,,percent of total billed charges,,,,,,,,,36.56,,,percent of total billed charges,,,20.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.56,,,percent of total billed charges,,,,,,,,,,,,,,,36.56,,,percent of total billed charges,,,19.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,36.56,,,percent of total billed charges,,,36.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.67,,,percent of total billed charges,,
BUDESONIDE 0.5 MG/2 ML NEB SOL,2500007785,CDM,637,RC,J7626,HCPCS,93681655,NDC,,,,outpatient,facility,2,UN,36.56,36.56,0.66,618.77,,21.35,,,percent of total billed charges,,,7.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,36.56,,,percent of total billed charges,,,1.41,,,fee schedule,,,1.36,,,fee schedule,,,,,,,,,1.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,36.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,13.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,32.9,,,percent of total billed charges,,,,,,,,,36.56,,,percent of total billed charges,,,24.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.08,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,fee schedule,,,1.01,,,fee schedule,,,,,,,,,618.77,,,per diem,,,36.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.06,,,percent of total billed charges,,,36.56,,,percent of total billed charges,,,36.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.79,,,percent of total billed charges,,,13.85,,,percent of total billed charges,,,18.93,,,percent of total billed charges,,,,,,,,,,,,,,,7.31,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.12,,,fee schedule,,,0.94,,,fee schedule,,,36.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,36.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.92,,,percent of total billed charges,,,36.56,,,percent of total billed charges,,,36.56,,,percent of total billed charges,,,,,,,,,,,,,,,36.56,,,percent of total billed charges,,,36.56,,,percent of total billed charges,,,,,,,,,1.23,,,fee schedule,,,1.01,,,fee schedule,,,,,,,,,,,,,,,0.89,,,fee schedule,,,1.18,,,fee schedule,,,0.66,,,fee schedule,,,1.23,,,fee schedule,,,36.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,36.56,,,percent of total billed charges,,,36.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,25.67,,,percent of total billed charges,,
BUDESONIDE 0.5 MG/2 ML NEB SOL,2500007785,CDM,637,RC,J7626,HCPCS,93681655,NDC,496,EAPG,,outpatient,facility,2,UN,36.56,36.56,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUDESONIDE 3MG CAP,2500007787,CDM,637,RC,6516277810,NDC,,,,,,inpatient,facility,3,UN,82.03,82.03,6.56,82.03,,,,,,,,,,,,,,82.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.83,,,percent of total billed charges,,,,,,,,,82.03,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.03,,,percent of total billed charges,,,,,,,,,,,,,,,82.03,,,percent of total billed charges,,,42.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,82.03,,,percent of total billed charges,,,82.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.6,,,percent of total billed charges,,
BUDESONIDE 3MG CAP,2500007787,CDM,637,RC,6516277810,NDC,,,,,,outpatient,facility,3,UN,82.03,82.03,6.56,618.77,,47.91,,,percent of total billed charges,,,16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,82.03,,,percent of total billed charges,,,72.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,72.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,72.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,82.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,30.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,73.83,,,percent of total billed charges,,,,,,,,,82.03,,,percent of total billed charges,,,55.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63,,,percent of total billed charges,,,,,,,,,,,,,,,44.3,,,percent of total billed charges,,,44.3,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,82.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.77,,,percent of total billed charges,,,82.03,,,percent of total billed charges,,,82.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.34,,,percent of total billed charges,,,31.07,,,percent of total billed charges,,,42.48,,,percent of total billed charges,,,,,,,,,,,,,,,16.41,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,30.35,,,percent of total billed charges,,,30.35,,,percent of total billed charges,,,82.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,82.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.56,,,percent of total billed charges,,,82.03,,,percent of total billed charges,,,82.03,,,percent of total billed charges,,,,,,,,,,,,,,,82.03,,,percent of total billed charges,,,82.03,,,percent of total billed charges,,,,,,,,,82.03,,,fee schedule,,,76.3,,,percent of total billed charges,,,,,,,,,,,,,,,76.3,,,percent of total billed charges,,,76.3,,,percent of total billed charges,,,76.3,,,percent of total billed charges,,,61.52,,,percent of total billed charges,,,82.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,82.03,,,percent of total billed charges,,,82.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,57.6,,,percent of total billed charges,,
BUDESONIDE 3MG CAP,2500007787,CDM,637,RC,6516277810,NDC,999,EAPG,,,,outpatient,facility,3,UN,82.03,82.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUMETANIDE 0.25 MG/ML 10ML INJ,2500007790,CDM,250,RC,J3490,HCPCS,641600710,NDC,,,,inpatient,facility,10,UN,10.82,10.82,0.87,10.82,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.74,,,percent of total billed charges,,,,,,,,,10.82,,,percent of total billed charges,,,5.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.6,,,percent of total billed charges,,
BUMETANIDE 0.25 MG/ML 10ML INJ,2500007790,CDM,250,RC,J3490,HCPCS,641600710,NDC,,,,outpatient,facility,10,UN,10.82,10.82,0.87,618.77,,6.32,,,percent of total billed charges,,,2.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.82,,,percent of total billed charges,,,9.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,9.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,9.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.74,,,percent of total billed charges,,,,,,,,,10.82,,,percent of total billed charges,,,7.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.31,,,percent of total billed charges,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.22,,,percent of total billed charges,,,4.1,,,percent of total billed charges,,,5.6,,,percent of total billed charges,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,10.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.87,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,,,,,,,10.82,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,8.12,,,percent of total billed charges,,,10.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.82,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.6,,,percent of total billed charges,,
BUMETANIDE 0.25 MG/ML 10ML INJ,2500007790,CDM,250,RC,J3490,HCPCS,641600710,NDC,435,EAPG,,outpatient,facility,10,UN,10.82,10.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUMETANIDE 0.25 MG/ML 4 ML INJ,2500007792,CDM,250,RC,J3490,HCPCS,409141204,NDC,,,,inpatient,facility,4,ML,7.03,7.03,0.56,7.03,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,,,,,,,7.03,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,3.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,
BUMETANIDE 0.25 MG/ML 4 ML INJ,2500007792,CDM,250,RC,J3490,HCPCS,409141204,NDC,,,,outpatient,facility,4,ML,7.03,7.03,0.56,618.77,,4.11,,,percent of total billed charges,,,1.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.03,,,percent of total billed charges,,,6.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.33,,,percent of total billed charges,,,,,,,,,7.03,,,percent of total billed charges,,,4.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.67,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.34,,,percent of total billed charges,,,2.66,,,percent of total billed charges,,,3.64,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,7.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,7.03,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,5.27,,,percent of total billed charges,,,7.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.94,,,percent of total billed charges,,
BUMETANIDE 0.25 MG/ML 4 ML INJ,2500007792,CDM,250,RC,J3490,HCPCS,409141204,NDC,435,EAPG,,outpatient,facility,4,ML,7.03,7.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUMETANIDE 0.5 MG/2ML VIAL INJ,2500007794,CDM,250,RC,J3490,HCPCS,,,,,,inpatient,facility,1,UN,4.46,4.46,0.36,4.46,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,,,,,,,4.46,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,
BUMETANIDE 0.5 MG/2ML VIAL INJ,2500007794,CDM,250,RC,J3490,HCPCS,,,,,,outpatient,facility,1,UN,4.46,4.46,0.36,618.77,,2.6,,,percent of total billed charges,,,0.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.46,,,percent of total billed charges,,,3.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.01,,,percent of total billed charges,,,,,,,,,4.46,,,percent of total billed charges,,,3.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,1.69,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,4.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.36,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,4.46,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.34,,,percent of total billed charges,,,4.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.13,,,percent of total billed charges,,
BUMETANIDE 0.5 MG/2ML VIAL INJ,2500007794,CDM,250,RC,J3490,HCPCS,435,EAPG,,,,outpatient,facility,1,UN,4.46,4.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUMETANIDE 1 MG TAB,2500007796,CDM,637,RC,6923814901,NDC,,,,,,inpatient,facility,1,UN,8.91,8.91,0.71,8.91,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.02,,,percent of total billed charges,,,,,,,,,8.91,,,percent of total billed charges,,,4.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,
BUMETANIDE 1 MG TAB,2500007796,CDM,637,RC,6923814901,NDC,,,,,,outpatient,facility,1,UN,8.91,8.91,0.71,618.77,,5.2,,,percent of total billed charges,,,1.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.91,,,percent of total billed charges,,,7.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.02,,,percent of total billed charges,,,,,,,,,8.91,,,percent of total billed charges,,,6.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,4.81,,,percent of total billed charges,,,4.81,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.77,,,percent of total billed charges,,,3.38,,,percent of total billed charges,,,4.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,8.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.71,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,8.91,,,fee schedule,,,8.29,,,percent of total billed charges,,,,,,,,,,,,,,,8.29,,,percent of total billed charges,,,8.29,,,percent of total billed charges,,,8.29,,,percent of total billed charges,,,6.68,,,percent of total billed charges,,,8.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.91,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.26,,,percent of total billed charges,,
BUMETANIDE 1 MG TAB,2500007796,CDM,637,RC,6923814901,NDC,999,EAPG,,,,outpatient,facility,1,UN,8.91,8.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPRENORPHINE 2 MG SL TAB,2500007804,CDM,637,RC,J0571,HCPCS,54017613,NDC,,,,inpatient,facility,2,UN,13.66,13.66,1.09,13.66,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.29,,,percent of total billed charges,,,,,,,,,13.66,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,7.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,13.66,,,percent of total billed charges,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.59,,,percent of total billed charges,,
BUPRENORPHINE 2 MG SL TAB,2500007804,CDM,637,RC,J0571,HCPCS,54017613,NDC,,,,outpatient,facility,2,UN,13.66,13.66,0.69,618.77,,7.98,,,percent of total billed charges,,,2.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.66,,,percent of total billed charges,,,0.91,,,fee schedule,,,0.88,,,fee schedule,,,,,,,,,0.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.29,,,percent of total billed charges,,,,,,,,,13.66,,,percent of total billed charges,,,9.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,fee schedule,,,0.69,,,fee schedule,,,,,,,,,618.77,,,per diem,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.12,,,percent of total billed charges,,,0.8,,,fee schedule,,,0.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.38,,,percent of total billed charges,,,5.17,,,percent of total billed charges,,,7.07,,,percent of total billed charges,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,13.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.09,,,percent of total billed charges,,,13.66,,,percent of total billed charges,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,13.66,,,percent of total billed charges,,,,,,,,,13.66,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,10.25,,,percent of total billed charges,,,13.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.66,,,percent of total billed charges,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.59,,,percent of total billed charges,,
BUPRENORPHINE 2 MG SL TAB,2500007804,CDM,637,RC,J0571,HCPCS,54017613,NDC,435,EAPG,,outpatient,facility,2,UN,13.66,13.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPROPION 75 MG TAB,2500007810,CDM,637,RC,6050501581,NDC,,,,,,inpatient,facility,75,UN,2.61,2.61,0.21,2.61,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,2.61,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,
BUPROPION 75 MG TAB,2500007810,CDM,637,RC,6050501581,NDC,,,,,,outpatient,facility,75,UN,2.61,2.61,0.21,618.77,,1.52,,,percent of total billed charges,,,0.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.61,,,percent of total billed charges,,,2.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.35,,,percent of total billed charges,,,,,,,,,2.61,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.97,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,2.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,2.61,,,fee schedule,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,2.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.83,,,percent of total billed charges,,
BUPROPION 75 MG TAB,2500007810,CDM,637,RC,6050501581,NDC,999,EAPG,,,,outpatient,facility,75,UN,2.61,2.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPROPION HCL 100 MG TAB,2500007813,CDM,637,RC,6050501571,NDC,,,,,,inpatient,facility,100,UN,3.5,3.5,0.28,3.5,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.15,,,percent of total billed charges,,,,,,,,,3.5,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,
BUPROPION HCL 100 MG TAB,2500007813,CDM,637,RC,6050501571,NDC,,,,,,outpatient,facility,100,UN,3.5,3.5,0.28,618.77,,2.04,,,percent of total billed charges,,,0.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.5,,,percent of total billed charges,,,3.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.15,,,percent of total billed charges,,,,,,,,,3.5,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.69,,,percent of total billed charges,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.66,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,3.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,3.5,,,fee schedule,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,2.63,,,percent of total billed charges,,,3.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.46,,,percent of total billed charges,,
BUPROPION HCL 100 MG TAB,2500007813,CDM,637,RC,6050501571,NDC,999,EAPG,,,,outpatient,facility,100,UN,3.5,3.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPROPION HCL 100 MG TABCR,2500007814,CDM,637,RC,6808469701,NDC,,,,,,inpatient,facility,100,UN,5.47,5.47,0.44,5.47,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,,,,,,,5.47,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,5.47,,,percent of total billed charges,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.84,,,percent of total billed charges,,
BUPROPION HCL 100 MG TABCR,2500007814,CDM,637,RC,6808469701,NDC,,,,,,outpatient,facility,100,UN,5.47,5.47,0.44,618.77,,3.19,,,percent of total billed charges,,,1.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.47,,,percent of total billed charges,,,4.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.92,,,percent of total billed charges,,,,,,,,,5.47,,,percent of total billed charges,,,3.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.2,,,percent of total billed charges,,,,,,,,,,,,,,,2.95,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,5.47,,,percent of total billed charges,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.02,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,5.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.44,,,percent of total billed charges,,,5.47,,,percent of total billed charges,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,5.47,,,percent of total billed charges,,,,,,,,,5.47,,,fee schedule,,,5.09,,,percent of total billed charges,,,,,,,,,,,,,,,5.09,,,percent of total billed charges,,,5.09,,,percent of total billed charges,,,5.09,,,percent of total billed charges,,,4.1,,,percent of total billed charges,,,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.47,,,percent of total billed charges,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.84,,,percent of total billed charges,,
BUPROPION HCL 100 MG TABCR,2500007814,CDM,637,RC,6808469701,NDC,999,EAPG,,,,outpatient,facility,100,UN,5.47,5.47,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPROPION HCL 150 MG TABCR,2500007815,CDM,637,RC,904658561,NDC,,,,,,inpatient,facility,150,UN,1.95,1.95,0.16,1.95,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,1.95,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,
BUPROPION HCL 150 MG TABCR,2500007815,CDM,637,RC,904658561,NDC,,,,,,outpatient,facility,150,UN,1.95,1.95,0.16,618.77,,1.14,,,percent of total billed charges,,,0.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.95,,,percent of total billed charges,,,1.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.75,,,percent of total billed charges,,,,,,,,,1.95,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.72,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,1.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,1.95,,,fee schedule,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,1.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.37,,,percent of total billed charges,,
BUPROPION HCL 150 MG TABCR,2500007815,CDM,637,RC,904658561,NDC,999,EAPG,,,,outpatient,facility,150,UN,1.95,1.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPROPION HCL 150 MG TAB XL,2500007817,CDM,637,RC,6818031906,NDC,,,,,,inpatient,facility,150,UN,15.74,15.74,1.26,15.74,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.17,,,percent of total billed charges,,,,,,,,,15.74,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,8.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.05,,,percent of total billed charges,,
BUPROPION HCL 150 MG TAB XL,2500007817,CDM,637,RC,6818031906,NDC,,,,,,outpatient,facility,150,UN,15.74,15.74,1.26,618.77,,9.19,,,percent of total billed charges,,,3.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,15.74,,,percent of total billed charges,,,13.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,13.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,13.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,14.17,,,percent of total billed charges,,,,,,,,,15.74,,,percent of total billed charges,,,10.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,,,,,,,,,,,,,8.5,,,percent of total billed charges,,,8.5,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.21,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.96,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,3.15,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.82,,,percent of total billed charges,,,5.82,,,percent of total billed charges,,,15.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.26,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,15.74,,,fee schedule,,,14.64,,,percent of total billed charges,,,,,,,,,,,,,,,14.64,,,percent of total billed charges,,,14.64,,,percent of total billed charges,,,14.64,,,percent of total billed charges,,,11.8,,,percent of total billed charges,,,15.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,15.74,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.05,,,percent of total billed charges,,
BUPROPION HCL 150 MG TAB XL,2500007817,CDM,637,RC,6818031906,NDC,999,EAPG,,,,outpatient,facility,150,UN,15.74,15.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUSPIRONE HCL 10 MG TAB,2500007830,CDM,637,RC,2315502405,NDC,,,,,,inpatient,facility,10,UN,4.29,4.29,0.34,4.29,,,,,,,,,,,,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.86,,,percent of total billed charges,,,,,,,,,4.29,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,,4.29,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,4.29,,,percent of total billed charges,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,
BUSPIRONE HCL 10 MG TAB,2500007830,CDM,637,RC,2315502405,NDC,,,,,,outpatient,facility,10,UN,4.29,4.29,0.34,618.77,,2.51,,,percent of total billed charges,,,0.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.29,,,percent of total billed charges,,,3.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.86,,,percent of total billed charges,,,,,,,,,4.29,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.29,,,percent of total billed charges,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,2.32,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,4.29,,,percent of total billed charges,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.59,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,4.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.34,,,percent of total billed charges,,,4.29,,,percent of total billed charges,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,,4.29,,,percent of total billed charges,,,4.29,,,percent of total billed charges,,,,,,,,,4.29,,,fee schedule,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.22,,,percent of total billed charges,,,4.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.29,,,percent of total billed charges,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.01,,,percent of total billed charges,,
BUSPIRONE HCL 10 MG TAB,2500007830,CDM,637,RC,2315502405,NDC,999,EAPG,,,,outpatient,facility,10,UN,4.29,4.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUSPIRONE HCL 5 MG TAB,2500007833,CDM,637,RC,5107998520,NDC,,,,,,inpatient,facility,5,UN,2.54,2.54,0.2,2.54,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.29,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,
BUSPIRONE HCL 5 MG TAB,2500007833,CDM,637,RC,5107998520,NDC,,,,,,outpatient,facility,5,UN,2.54,2.54,0.2,618.77,,1.48,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.54,,,percent of total billed charges,,,2.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.29,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.94,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,2.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,2.54,,,fee schedule,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,2.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.78,,,percent of total billed charges,,
BUSPIRONE HCL 5 MG TAB,2500007833,CDM,637,RC,5107998520,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.54,2.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAFFEINE/SOD BEN 500MG/2ML INJ,2500007862,CDM,250,RC,517250210,NDC,,,,,,inpatient,facility,2,UN,112.37,112.37,8.99,112.37,,,,,,,,,,,,,,112.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.13,,,percent of total billed charges,,,,,,,,,112.37,,,percent of total billed charges,,,62.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.37,,,percent of total billed charges,,,,,,,,,,,,,,,112.37,,,percent of total billed charges,,,58.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.99,,,percent of total billed charges,,,112.37,,,percent of total billed charges,,,112.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.91,,,percent of total billed charges,,
CAFFEINE/SOD BEN 500MG/2ML INJ,2500007862,CDM,250,RC,517250210,NDC,,,,,,outpatient,facility,2,UN,112.37,112.37,8.99,618.77,,65.62,,,percent of total billed charges,,,21.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,112.37,,,percent of total billed charges,,,98.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,98.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,98.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,112.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,41.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,101.13,,,percent of total billed charges,,,,,,,,,112.37,,,percent of total billed charges,,,76.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,112.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,112.37,,,percent of total billed charges,,,112.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.4,,,percent of total billed charges,,,42.57,,,percent of total billed charges,,,58.2,,,percent of total billed charges,,,,,,,,,,,,,,,22.47,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,44.95,,,percent of total billed charges,,,44.95,,,percent of total billed charges,,,112.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,112.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.99,,,percent of total billed charges,,,112.37,,,percent of total billed charges,,,112.37,,,percent of total billed charges,,,,,,,,,,,,,,,112.37,,,percent of total billed charges,,,112.37,,,percent of total billed charges,,,,,,,,,112.37,,,fee schedule,,,44.95,,,percent of total billed charges,,,,,,,,,,,,,,,44.95,,,percent of total billed charges,,,44.95,,,percent of total billed charges,,,44.95,,,percent of total billed charges,,,84.28,,,percent of total billed charges,,,112.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,112.37,,,percent of total billed charges,,,112.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,78.91,,,percent of total billed charges,,
CAFFEINE/SOD BEN 500MG/2ML INJ,2500007862,CDM,250,RC,517250210,NDC,999,EAPG,,,,outpatient,facility,2,UN,112.37,112.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALAMINE LOTION 180 ML,2500007881,CDM,637,RC,904253321,NDC,,,,,,inpatient,facility,180,UN,2.28,2.28,0.18,2.28,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,2.28,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,
CALAMINE LOTION 180 ML,2500007881,CDM,637,RC,904253321,NDC,,,,,,outpatient,facility,180,UN,2.28,2.28,0.18,618.77,,1.33,,,percent of total billed charges,,,0.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.28,,,percent of total billed charges,,,2.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.05,,,percent of total billed charges,,,,,,,,,2.28,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.84,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,2.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,2.28,,,fee schedule,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,2.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.6,,,percent of total billed charges,,
CALAMINE LOTION 180 ML,2500007881,CDM,637,RC,904253321,NDC,999,EAPG,,,,outpatient,facility,180,UN,2.28,2.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCIPOTRIENE 0.005  OINT 60 G,2500007916,CDM,637,RC,6699387761,NDC,,,,,,inpatient,facility,60,UN,1398.18,1398.18,111.85,1398.18,,,,,,,,,,,,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1258.36,,,percent of total billed charges,,,,,,,,,1398.18,,,percent of total billed charges,,,774.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1275.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,1398.18,,,percent of total billed charges,,,729.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.85,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,981.8,,,percent of total billed charges,,
CALCIPOTRIENE 0.005  OINT 60 G,2500007916,CDM,637,RC,6699387761,NDC,,,,,,outpatient,facility,60,UN,1398.18,1398.18,111.85,1398.18,,816.54,,,percent of total billed charges,,,272.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1398.18,,,percent of total billed charges,,,1230.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1230.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1230.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,511.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1258.36,,,percent of total billed charges,,,,,,,,,1398.18,,,percent of total billed charges,,,946.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1073.8,,,percent of total billed charges,,,,,,,,,,,,,,,755.02,,,percent of total billed charges,,,755.02,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,729.01,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1062.62,,,percent of total billed charges,,,529.63,,,percent of total billed charges,,,724.12,,,percent of total billed charges,,,,,,,,,,,,,,,279.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,517.33,,,percent of total billed charges,,,517.33,,,percent of total billed charges,,,1398.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1398.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,111.85,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,1398.18,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,,,,,,,1398.18,,,fee schedule,,,1300.59,,,percent of total billed charges,,,,,,,,,,,,,,,1300.59,,,percent of total billed charges,,,1300.59,,,percent of total billed charges,,,1300.59,,,percent of total billed charges,,,1048.63,,,percent of total billed charges,,,1398.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1398.18,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,699.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,981.8,,,percent of total billed charges,,
CALCIPOTRIENE 0.005  OINT 60 G,2500007916,CDM,637,RC,6699387761,NDC,999,EAPG,,,,outpatient,facility,60,UN,1398.18,1398.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCITRIOL 0.25 MCG CAP,2500007930,CDM,637,RC,2315566201,NDC,,,,,,inpatient,facility,0.25,UN,3.99,3.99,0.32,3.99,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.59,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,
CALCITRIOL 0.25 MCG CAP,2500007930,CDM,637,RC,2315566201,NDC,,,,,,outpatient,facility,0.25,UN,3.99,3.99,0.32,618.77,,2.33,,,percent of total billed charges,,,0.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.99,,,percent of total billed charges,,,3.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.59,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.48,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,3.99,,,fee schedule,,,3.71,,,percent of total billed charges,,,,,,,,,,,,,,,3.71,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,3.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.8,,,percent of total billed charges,,
CALCITRIOL 0.25 MCG CAP,2500007930,CDM,637,RC,2315566201,NDC,999,EAPG,,,,outpatient,facility,0.25,UN,3.99,3.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCIUM ACETATE 667 MG TAB,2500007940,CDM,637,RC,781208102,NDC,,,,,,inpatient,facility,667,UN,0.49,0.49,0.04,0.49,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,
CALCIUM ACETATE 667 MG TAB,2500007940,CDM,637,RC,781208102,NDC,,,,,,outpatient,facility,667,UN,0.49,0.49,0.04,618.77,,0.29,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.49,,,percent of total billed charges,,,0.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.44,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.18,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,0.49,,,fee schedule,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,0.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.34,,,percent of total billed charges,,
CALCIUM ACETATE 667 MG TAB,2500007940,CDM,637,RC,781208102,NDC,999,EAPG,,,,outpatient,facility,667,UN,0.49,0.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCIUM CARB 500 MG CHEW TAB,2500007950,CDM,637,RC,6655300401,NDC,,,,,,inpatient,facility,500,UN,1.62,1.62,0.13,1.62,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.46,,,percent of total billed charges,,,,,,,,,1.62,,,percent of total billed charges,,,0.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,
CALCIUM CARB 500 MG CHEW TAB,2500007950,CDM,637,RC,6655300401,NDC,,,,,,outpatient,facility,500,UN,1.62,1.62,0.13,618.77,,0.95,,,percent of total billed charges,,,0.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.62,,,percent of total billed charges,,,1.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.46,,,percent of total billed charges,,,,,,,,,1.62,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.6,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,1.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,1.62,,,fee schedule,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.62,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.14,,,percent of total billed charges,,
CALCIUM CARB 500 MG CHEW TAB,2500007950,CDM,637,RC,6655300401,NDC,999,EAPG,,,,outpatient,facility,500,UN,1.62,1.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCIUM CL 10  10ML SYR INJ,2500007960,CDM,250,RC,J3490,HCPCS,7632933041,NDC,,,,inpatient,facility,10,UN,29.7,29.7,2.38,29.7,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.73,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,16.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,15.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.86,,,percent of total billed charges,,
CALCIUM CL 10  10ML SYR INJ,2500007960,CDM,250,RC,J3490,HCPCS,7632933041,NDC,,,,outpatient,facility,10,UN,29.7,29.7,1.2,618.77,,17.34,,,percent of total billed charges,,,5.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,29.7,,,percent of total billed charges,,,26.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,26.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,26.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26.73,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,20.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.81,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.49,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,15.38,,,percent of total billed charges,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,29.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.38,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,29.7,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,22.27,,,percent of total billed charges,,,29.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.86,,,percent of total billed charges,,
CALCIUM CL 10  10ML SYR INJ,2500007960,CDM,250,RC,J3490,HCPCS,7632933041,NDC,435,EAPG,,outpatient,facility,10,UN,29.7,29.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAMPHOR/MENTHOL/PHENOL 225 ML,2500008060,CDM,637,RC,536126812,NDC,,,,,,inpatient,facility,225,UN,7.86,7.86,0.63,7.86,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,,,,,,,,7.86,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,4.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.52,,,percent of total billed charges,,
CAMPHOR/MENTHOL/PHENOL 225 ML,2500008060,CDM,637,RC,536126812,NDC,,,,,,outpatient,facility,225,UN,7.86,7.86,0.63,618.77,,4.59,,,percent of total billed charges,,,1.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.86,,,percent of total billed charges,,,6.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.07,,,percent of total billed charges,,,,,,,,,7.86,,,percent of total billed charges,,,5.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.04,,,percent of total billed charges,,,,,,,,,,,,,,,4.24,,,percent of total billed charges,,,4.24,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,4.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.91,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,7.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.63,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,,,,,,,7.86,,,fee schedule,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,7.31,,,percent of total billed charges,,,7.31,,,percent of total billed charges,,,7.31,,,percent of total billed charges,,,5.9,,,percent of total billed charges,,,7.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.52,,,percent of total billed charges,,
CAMPHOR/MENTHOL/PHENOL 225 ML,2500008060,CDM,637,RC,536126812,NDC,999,EAPG,,,,outpatient,facility,225,UN,7.86,7.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAPTOPRIL 12.5 MG TAB,2500008110,CDM,637,RC,2724116001,NDC,,,,,,inpatient,facility,12.5,UN,5.15,5.15,0.41,5.15,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.64,,,percent of total billed charges,,,,,,,,,5.15,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,2.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.62,,,percent of total billed charges,,
CAPTOPRIL 12.5 MG TAB,2500008110,CDM,637,RC,2724116001,NDC,,,,,,outpatient,facility,12.5,UN,5.15,5.15,0.41,618.77,,3.01,,,percent of total billed charges,,,1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.15,,,percent of total billed charges,,,4.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.64,,,percent of total billed charges,,,,,,,,,5.15,,,percent of total billed charges,,,3.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,2.78,,,percent of total billed charges,,,2.78,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.69,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.91,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,5.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.41,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,,,,,,,5.15,,,fee schedule,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,4.79,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,3.86,,,percent of total billed charges,,,5.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.15,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.62,,,percent of total billed charges,,
CAPTOPRIL 12.5 MG TAB,2500008110,CDM,637,RC,2724116001,NDC,999,EAPG,,,,outpatient,facility,12.5,UN,5.15,5.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAPTOPRIL 25 MG TAB,2500008113,CDM,637,RC,2724116101,NDC,,,,,,inpatient,facility,25,UN,4.19,4.19,0.34,4.19,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.77,,,percent of total billed charges,,,,,,,,,4.19,,,percent of total billed charges,,,2.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,
CAPTOPRIL 25 MG TAB,2500008113,CDM,637,RC,2724116101,NDC,,,,,,outpatient,facility,25,UN,4.19,4.19,0.34,618.77,,2.45,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.19,,,percent of total billed charges,,,3.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.77,,,percent of total billed charges,,,,,,,,,4.19,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,2.26,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.18,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,4.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.34,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,4.19,,,fee schedule,,,3.9,,,percent of total billed charges,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,3.9,,,percent of total billed charges,,,3.9,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,4.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.94,,,percent of total billed charges,,
CAPTOPRIL 25 MG TAB,2500008113,CDM,637,RC,2724116101,NDC,999,EAPG,,,,outpatient,facility,25,UN,4.19,4.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBAMAZEPINE 100 MG CHEW TAB,2500008130,CDM,637,RC,904385461,NDC,,,,,,inpatient,facility,100,UN,1.68,1.68,0.13,1.68,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
CARBAMAZEPINE 100 MG CHEW TAB,2500008130,CDM,637,RC,904385461,NDC,,,,,,outpatient,facility,100,UN,1.68,1.68,0.13,618.77,,0.98,,,percent of total billed charges,,,0.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.68,,,percent of total billed charges,,,1.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.51,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,1.68,,,fee schedule,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.18,,,percent of total billed charges,,
CARBAMAZEPINE 100 MG CHEW TAB,2500008130,CDM,637,RC,904385461,NDC,999,EAPG,,,,outpatient,facility,100,UN,1.68,1.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBAMAZEPINE 100 MG XR TAB,2500008131,CDM,637,RC,5167241231,NDC,,,,,,inpatient,facility,100,UN,3.76,3.76,0.3,3.76,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,
CARBAMAZEPINE 100 MG XR TAB,2500008131,CDM,637,RC,5167241231,NDC,,,,,,outpatient,facility,100,UN,3.76,3.76,0.3,618.77,,2.2,,,percent of total billed charges,,,0.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.76,,,percent of total billed charges,,,3.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.38,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,3.76,,,fee schedule,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,2.82,,,percent of total billed charges,,,3.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.64,,,percent of total billed charges,,
CARBAMAZEPINE 100 MG XR TAB,2500008131,CDM,637,RC,5167241231,NDC,999,EAPG,,,,outpatient,facility,100,UN,3.76,3.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBAMAZEPINE 200 MG/10 ML UDC,2500008136,CDM,637,RC,121172430,NDC,,,,,,inpatient,facility,10,UN,14.98,14.98,1.2,14.98,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.48,,,percent of total billed charges,,,,,,,,,14.98,,,percent of total billed charges,,,8.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,7.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.52,,,percent of total billed charges,,
CARBAMAZEPINE 200 MG/10 ML UDC,2500008136,CDM,637,RC,121172430,NDC,,,,,,outpatient,facility,10,UN,14.98,14.98,1.2,618.77,,8.75,,,percent of total billed charges,,,2.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.98,,,percent of total billed charges,,,13.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,13.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,13.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.48,,,percent of total billed charges,,,,,,,,,14.98,,,percent of total billed charges,,,10.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.5,,,percent of total billed charges,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.81,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.38,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,7.76,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.54,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,14.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.2,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,14.98,,,fee schedule,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,11.23,,,percent of total billed charges,,,14.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.52,,,percent of total billed charges,,
CARBAMAZEPINE 200 MG/10 ML UDC,2500008136,CDM,637,RC,121172430,NDC,999,EAPG,,,,outpatient,facility,10,UN,14.98,14.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBAMAZEPINE 200 MG TAB,2500008140,CDM,637,RC,904617261,NDC,,,,,,inpatient,facility,200,UN,2.97,2.97,0.24,2.97,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.09,,,percent of total billed charges,,
CARBAMAZEPINE 200 MG TAB,2500008140,CDM,637,RC,904617261,NDC,,,,,,outpatient,facility,200,UN,2.97,2.97,0.24,618.77,,1.73,,,percent of total billed charges,,,0.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.97,,,percent of total billed charges,,,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.67,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,fee schedule,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.09,,,percent of total billed charges,,
CARBAMAZEPINE 200 MG TAB,2500008140,CDM,637,RC,904617261,NDC,999,EAPG,,,,outpatient,facility,200,UN,2.97,2.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBAMAZEPINE 400 MG XR TAB,2500008144,CDM,637,RC,5167241251,NDC,,,,,,inpatient,facility,400,UN,13.69,13.69,1.1,13.69,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.32,,,percent of total billed charges,,,,,,,,,13.69,,,percent of total billed charges,,,7.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,7.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.61,,,percent of total billed charges,,
CARBAMAZEPINE 400 MG XR TAB,2500008144,CDM,637,RC,5167241251,NDC,,,,,,outpatient,facility,400,UN,13.69,13.69,1.1,618.77,,7.99,,,percent of total billed charges,,,2.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.69,,,percent of total billed charges,,,12.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.32,,,percent of total billed charges,,,,,,,,,13.69,,,percent of total billed charges,,,9.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.51,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.14,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.4,,,percent of total billed charges,,,5.19,,,percent of total billed charges,,,7.09,,,percent of total billed charges,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.07,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,13.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,13.69,,,fee schedule,,,12.73,,,percent of total billed charges,,,,,,,,,,,,,,,12.73,,,percent of total billed charges,,,12.73,,,percent of total billed charges,,,12.73,,,percent of total billed charges,,,10.27,,,percent of total billed charges,,,13.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.61,,,percent of total billed charges,,
CARBAMAZEPINE 400 MG XR TAB,2500008144,CDM,637,RC,5167241251,NDC,999,EAPG,,,,outpatient,facility,400,UN,13.69,13.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBIDOPA/LEVODOP 10/100 TAB,2500008170,CDM,637,RC,6275651788,NDC,,,,,,inpatient,facility,1,UN,0.86,0.86,0.07,0.86,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,,,,,,,0.86,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 10/100 TAB,2500008170,CDM,637,RC,6275651788,NDC,,,,,,outpatient,facility,1,UN,0.86,0.86,0.07,618.77,,0.5,,,percent of total billed charges,,,0.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.86,,,percent of total billed charges,,,0.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.77,,,percent of total billed charges,,,,,,,,,0.86,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.32,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,0.86,,,fee schedule,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,0.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.6,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 10/100 TAB,2500008170,CDM,637,RC,6275651788,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.86,0.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBIDOPA/LEVODOP 25/100 TAB,2500008172,CDM,637,RC,904623761,NDC,,,,,,inpatient,facility,1,UN,0.62,0.62,0.05,0.62,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 25/100 TAB,2500008172,CDM,637,RC,904623761,NDC,,,,,,outpatient,facility,1,UN,0.62,0.62,0.05,618.77,,0.36,,,percent of total billed charges,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.62,,,percent of total billed charges,,,0.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.56,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,0.62,,,fee schedule,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.44,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 25/100 TAB,2500008172,CDM,637,RC,904623761,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.62,0.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBIDOPA/LEVODOP 25/100 TABCR,2500008173,CDM,637,RC,5107997801,NDC,,,,,,inpatient,facility,1,UN,5.74,5.74,0.46,5.74,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,,,,,,,5.74,,,percent of total billed charges,,,3.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 25/100 TABCR,2500008173,CDM,637,RC,5107997801,NDC,,,,,,outpatient,facility,1,UN,5.74,5.74,0.46,618.77,,3.35,,,percent of total billed charges,,,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.74,,,percent of total billed charges,,,5.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.17,,,percent of total billed charges,,,,,,,,,5.74,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.41,,,percent of total billed charges,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.99,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.36,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,5.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,5.74,,,fee schedule,,,5.34,,,percent of total billed charges,,,,,,,,,,,,,,,5.34,,,percent of total billed charges,,,5.34,,,percent of total billed charges,,,5.34,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,5.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.03,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 25/100 TABCR,2500008173,CDM,637,RC,5107997801,NDC,999,EAPG,,,,outpatient,facility,1,UN,5.74,5.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBIDOPA/LEVODOP 25/250 TAB,2500008174,CDM,637,RC,904623861,NDC,,,,,,inpatient,facility,1,UN,0.82,0.82,0.07,0.82,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 25/250 TAB,2500008174,CDM,637,RC,904623861,NDC,,,,,,outpatient,facility,1,UN,0.82,0.82,0.07,618.77,,0.48,,,percent of total billed charges,,,0.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.82,,,percent of total billed charges,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.74,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,0.82,,,fee schedule,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.58,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 25/250 TAB,2500008174,CDM,637,RC,904623861,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.82,0.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBIDOPA/LEVODOP 50/200 TABCR,2500008177,CDM,637,RC,5107992320,NDC,,,,,,inpatient,facility,1,UN,5.74,5.74,0.46,5.74,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,,,,,,,5.74,,,percent of total billed charges,,,3.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 50/200 TABCR,2500008177,CDM,637,RC,5107992320,NDC,,,,,,outpatient,facility,1,UN,5.74,5.74,0.46,618.77,,3.35,,,percent of total billed charges,,,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.74,,,percent of total billed charges,,,5.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.17,,,percent of total billed charges,,,,,,,,,5.74,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.41,,,percent of total billed charges,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.99,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.36,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,5.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,5.74,,,fee schedule,,,5.34,,,percent of total billed charges,,,,,,,,,,,,,,,5.34,,,percent of total billed charges,,,5.34,,,percent of total billed charges,,,5.34,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,5.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.03,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 50/200 TABCR,2500008177,CDM,637,RC,5107992320,NDC,999,EAPG,,,,outpatient,facility,1,UN,5.74,5.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARVEDILOL 12.5 MG TAB,2500008250,CDM,637,RC,904630261,NDC,,,,,,inpatient,facility,12.5,UN,0.26,0.26,0.02,0.26,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,
CARVEDILOL 12.5 MG TAB,2500008250,CDM,637,RC,904630261,NDC,,,,,,outpatient,facility,12.5,UN,0.26,0.26,0.02,618.77,,0.15,,,percent of total billed charges,,,0.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,0.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.23,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.1,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,0.26,,,fee schedule,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.18,,,percent of total billed charges,,
CARVEDILOL 12.5 MG TAB,2500008250,CDM,637,RC,904630261,NDC,999,EAPG,,,,outpatient,facility,12.5,UN,0.26,0.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARVEDILOL 25 MG TAB,2500008251,CDM,637,RC,904630361,NDC,,,,,,inpatient,facility,25,UN,0.26,0.26,0.02,0.26,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,
CARVEDILOL 25 MG TAB,2500008251,CDM,637,RC,904630361,NDC,,,,,,outpatient,facility,25,UN,0.26,0.26,0.02,618.77,,0.15,,,percent of total billed charges,,,0.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,0.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.23,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.1,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,0.26,,,fee schedule,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.18,,,percent of total billed charges,,
CARVEDILOL 25 MG TAB,2500008251,CDM,637,RC,904630361,NDC,999,EAPG,,,,outpatient,facility,25,UN,0.26,0.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARVEDILOL 6.25 MG TAB,2500008254,CDM,637,RC,904630161,NDC,,,,,,inpatient,facility,6.25,UN,0.29,0.29,0.02,0.29,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,
CARVEDILOL 6.25 MG TAB,2500008254,CDM,637,RC,904630161,NDC,,,,,,outpatient,facility,6.25,UN,0.29,0.29,0.02,618.77,,0.17,,,percent of total billed charges,,,0.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.29,,,percent of total billed charges,,,0.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.26,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.11,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,fee schedule,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.2,,,percent of total billed charges,,
CARVEDILOL 6.25 MG TAB,2500008254,CDM,637,RC,904630161,NDC,999,EAPG,,,,outpatient,facility,6.25,UN,0.29,0.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFEPIME HCL 1 GM INJ,2500008322,CDM,636,RC,J0692,HCPCS,4456724010,NDC,,,,inpatient,facility,1,UN,22.57,22.57,1.81,22.57,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.31,,,percent of total billed charges,,,,,,,,,22.57,,,percent of total billed charges,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,11.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,22.57,,,percent of total billed charges,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.85,,,percent of total billed charges,,
CEFEPIME HCL 1 GM INJ,2500008322,CDM,636,RC,J0692,HCPCS,4456724010,NDC,,,,outpatient,facility,1,UN,22.57,22.57,1.32,618.77,,13.18,,,percent of total billed charges,,,4.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,22.57,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,20.31,,,percent of total billed charges,,,,,,,,,22.57,,,percent of total billed charges,,,15.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.77,,,percent of total billed charges,,,22.57,,,percent of total billed charges,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.15,,,percent of total billed charges,,,8.55,,,percent of total billed charges,,,11.69,,,percent of total billed charges,,,,,,,,,,,,,,,4.51,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,22.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.81,,,percent of total billed charges,,,22.57,,,percent of total billed charges,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,22.57,,,percent of total billed charges,,,,,,,,,22.57,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.32,,,fee schedule,,,22.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,22.57,,,percent of total billed charges,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,15.85,,,percent of total billed charges,,
CEFEPIME HCL 1 GM INJ,2500008322,CDM,636,RC,J0692,HCPCS,4456724010,NDC,496,EAPG,,outpatient,facility,1,UN,22.57,22.57,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFEPIME HCL 2 GM INJ,2500008326,CDM,636,RC,J0692,HCPCS,4456724110,NDC,,,,inpatient,facility,2,UN,38.81,38.81,3.1,38.81,,,,,,,,,,,,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.93,,,percent of total billed charges,,,,,,,,,38.81,,,percent of total billed charges,,,21.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,38.81,,,percent of total billed charges,,,20.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,38.81,,,percent of total billed charges,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.25,,,percent of total billed charges,,
CEFEPIME HCL 2 GM INJ,2500008326,CDM,636,RC,J0692,HCPCS,4456724110,NDC,,,,outpatient,facility,2,UN,38.81,38.81,1.32,618.77,,22.67,,,percent of total billed charges,,,7.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,38.81,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,14.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,34.93,,,percent of total billed charges,,,,,,,,,38.81,,,percent of total billed charges,,,26.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.24,,,percent of total billed charges,,,38.81,,,percent of total billed charges,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.5,,,percent of total billed charges,,,14.7,,,percent of total billed charges,,,20.1,,,percent of total billed charges,,,,,,,,,,,,,,,7.76,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,38.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,38.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.1,,,percent of total billed charges,,,38.81,,,percent of total billed charges,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,38.81,,,percent of total billed charges,,,38.81,,,percent of total billed charges,,,,,,,,,38.81,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.32,,,fee schedule,,,38.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,38.81,,,percent of total billed charges,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,27.25,,,percent of total billed charges,,
CEFEPIME HCL 2 GM INJ,2500008326,CDM,636,RC,J0692,HCPCS,4456724110,NDC,496,EAPG,,outpatient,facility,2,UN,38.81,38.81,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFPODOXIME 200 MG TAB,2500008342,CDM,637,RC,6586209620,NDC,,,,,,inpatient,facility,200,UN,27.92,27.92,2.23,27.92,,,,,,,,,,,,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.13,,,percent of total billed charges,,,,,,,,,27.92,,,percent of total billed charges,,,15.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,27.92,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.61,,,percent of total billed charges,,
CEFPODOXIME 200 MG TAB,2500008342,CDM,637,RC,6586209620,NDC,,,,,,outpatient,facility,200,UN,27.92,27.92,2.23,618.77,,16.31,,,percent of total billed charges,,,5.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,27.92,,,percent of total billed charges,,,24.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,24.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,24.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,25.13,,,percent of total billed charges,,,,,,,,,27.92,,,percent of total billed charges,,,18.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.44,,,percent of total billed charges,,,,,,,,,,,,,,,15.08,,,percent of total billed charges,,,15.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.56,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.22,,,percent of total billed charges,,,10.58,,,percent of total billed charges,,,14.46,,,percent of total billed charges,,,,,,,,,,,,,,,5.58,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.33,,,percent of total billed charges,,,10.33,,,percent of total billed charges,,,27.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.23,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,27.92,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,,,,,,,27.92,,,fee schedule,,,25.97,,,percent of total billed charges,,,,,,,,,,,,,,,25.97,,,percent of total billed charges,,,25.97,,,percent of total billed charges,,,25.97,,,percent of total billed charges,,,20.94,,,percent of total billed charges,,,27.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,27.92,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,19.61,,,percent of total billed charges,,
CEFPODOXIME 200 MG TAB,2500008342,CDM,637,RC,6586209620,NDC,999,EAPG,,,,outpatient,facility,200,UN,27.92,27.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFUROXIME AXETIL 250 MG TAB,2500008370,CDM,637,RC,6818030260,NDC,,,,,,inpatient,facility,250,UN,14.52,14.52,1.16,14.52,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.07,,,percent of total billed charges,,,,,,,,,14.52,,,percent of total billed charges,,,8.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,7.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.2,,,percent of total billed charges,,
CEFUROXIME AXETIL 250 MG TAB,2500008370,CDM,637,RC,6818030260,NDC,,,,,,outpatient,facility,250,UN,14.52,14.52,1.16,618.77,,8.48,,,percent of total billed charges,,,2.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.52,,,percent of total billed charges,,,12.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.07,,,percent of total billed charges,,,,,,,,,14.52,,,percent of total billed charges,,,9.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.15,,,percent of total billed charges,,,,,,,,,,,,,,,7.84,,,percent of total billed charges,,,7.84,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.57,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.04,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,7.52,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.37,,,percent of total billed charges,,,5.37,,,percent of total billed charges,,,14.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.16,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,,,,,,,14.52,,,fee schedule,,,13.51,,,percent of total billed charges,,,,,,,,,,,,,,,13.51,,,percent of total billed charges,,,13.51,,,percent of total billed charges,,,13.51,,,percent of total billed charges,,,10.89,,,percent of total billed charges,,,14.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.52,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.26,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.2,,,percent of total billed charges,,
CEFUROXIME AXETIL 250 MG TAB,2500008370,CDM,637,RC,6818030260,NDC,999,EAPG,,,,outpatient,facility,250,UN,14.52,14.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CELECOXIB 100 MG CAP,2500008380,CDM,637,RC,904650261,NDC,,,,,,inpatient,facility,100,UN,3.99,3.99,0.32,3.99,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.59,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,
CELECOXIB 100 MG CAP,2500008380,CDM,637,RC,904650261,NDC,,,,,,outpatient,facility,100,UN,3.99,3.99,0.32,618.77,,2.33,,,percent of total billed charges,,,0.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.99,,,percent of total billed charges,,,3.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.59,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.48,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,3.99,,,fee schedule,,,3.71,,,percent of total billed charges,,,,,,,,,,,,,,,3.71,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,3.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.8,,,percent of total billed charges,,
CELECOXIB 100 MG CAP,2500008380,CDM,637,RC,904650261,NDC,999,EAPG,,,,outpatient,facility,100,UN,3.99,3.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CELECOXIB 200 MG CAP,2500008382,CDM,637,RC,6909742112,NDC,,,,,,inpatient,facility,200,UN,25.01,25.01,2,25.01,,,,,,,,,,,,,,25.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.51,,,percent of total billed charges,,,,,,,,,25.01,,,percent of total billed charges,,,13.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.01,,,percent of total billed charges,,,,,,,,,,,,,,,25.01,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,25.01,,,percent of total billed charges,,,25.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.56,,,percent of total billed charges,,
CELECOXIB 200 MG CAP,2500008382,CDM,637,RC,6909742112,NDC,,,,,,outpatient,facility,200,UN,25.01,25.01,2,618.77,,14.61,,,percent of total billed charges,,,4.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,25.01,,,percent of total billed charges,,,22.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,22.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,22.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,25.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22.51,,,percent of total billed charges,,,,,,,,,25.01,,,percent of total billed charges,,,16.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.21,,,percent of total billed charges,,,,,,,,,,,,,,,13.51,,,percent of total billed charges,,,13.51,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,25.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,25.01,,,percent of total billed charges,,,25.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.01,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,12.95,,,percent of total billed charges,,,,,,,,,,,,,,,5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,9.25,,,percent of total billed charges,,,9.25,,,percent of total billed charges,,,25.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,,percent of total billed charges,,,25.01,,,percent of total billed charges,,,25.01,,,percent of total billed charges,,,,,,,,,,,,,,,25.01,,,percent of total billed charges,,,25.01,,,percent of total billed charges,,,,,,,,,25.01,,,fee schedule,,,23.26,,,percent of total billed charges,,,,,,,,,,,,,,,23.26,,,percent of total billed charges,,,23.26,,,percent of total billed charges,,,23.26,,,percent of total billed charges,,,18.76,,,percent of total billed charges,,,25.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,25.01,,,percent of total billed charges,,,25.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.56,,,percent of total billed charges,,
CELECOXIB 200 MG CAP,2500008382,CDM,637,RC,6909742112,NDC,999,EAPG,,,,outpatient,facility,200,UN,25.01,25.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEPHALEXIN HCL 250 MG CAP,2500008400,CDM,637,RC,6068715201,NDC,,,,,,inpatient,facility,250,UN,2.34,2.34,0.19,2.34,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,2.34,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,
CEPHALEXIN HCL 250 MG CAP,2500008400,CDM,637,RC,6068715201,NDC,,,,,,outpatient,facility,250,UN,2.34,2.34,0.19,618.77,,1.37,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.34,,,percent of total billed charges,,,2.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.11,,,percent of total billed charges,,,,,,,,,2.34,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.87,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,2.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,2.34,,,fee schedule,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,2.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.64,,,percent of total billed charges,,
CEPHALEXIN HCL 250 MG CAP,2500008400,CDM,637,RC,6068715201,NDC,999,EAPG,,,,outpatient,facility,250,UN,2.34,2.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEPHALEXIN HCL 500 MG CAP,2500008402,CDM,637,RC,5026815215,NDC,,,,,,inpatient,facility,500,UN,4.02,4.02,0.32,4.02,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.62,,,percent of total billed charges,,,,,,,,,4.02,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.82,,,percent of total billed charges,,
CEPHALEXIN HCL 500 MG CAP,2500008402,CDM,637,RC,5026815215,NDC,,,,,,outpatient,facility,500,UN,4.02,4.02,0.32,618.77,,2.35,,,percent of total billed charges,,,0.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.02,,,percent of total billed charges,,,3.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.62,,,percent of total billed charges,,,,,,,,,4.02,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.1,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.49,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,4.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.32,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,,,,,,,4.02,,,fee schedule,,,3.74,,,percent of total billed charges,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,,3.74,,,percent of total billed charges,,,3.74,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,4.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.02,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.82,,,percent of total billed charges,,
CEPHALEXIN HCL 500 MG CAP,2500008402,CDM,637,RC,5026815215,NDC,999,EAPG,,,,outpatient,facility,500,UN,4.02,4.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHARCOAL/SORBITOL 25 GM/120ML,2500008500,CDM,637,RC,574012074,NDC,,,,,,inpatient,facility,120,UN,25.05,25.05,2,25.05,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.55,,,percent of total billed charges,,,,,,,,,25.05,,,percent of total billed charges,,,13.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,13.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.59,,,percent of total billed charges,,
CHARCOAL/SORBITOL 25 GM/120ML,2500008500,CDM,637,RC,574012074,NDC,,,,,,outpatient,facility,120,UN,25.05,25.05,2,618.77,,14.63,,,percent of total billed charges,,,4.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,25.05,,,percent of total billed charges,,,22.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,22.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,22.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22.55,,,percent of total billed charges,,,,,,,,,25.05,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,13.53,,,percent of total billed charges,,,13.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.06,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,9.49,,,percent of total billed charges,,,12.97,,,percent of total billed charges,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,9.27,,,percent of total billed charges,,,9.27,,,percent of total billed charges,,,25.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,25.05,,,fee schedule,,,23.3,,,percent of total billed charges,,,,,,,,,,,,,,,23.3,,,percent of total billed charges,,,23.3,,,percent of total billed charges,,,23.3,,,percent of total billed charges,,,18.79,,,percent of total billed charges,,,25.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.59,,,percent of total billed charges,,
CHARCOAL/SORBITOL 25 GM/120ML,2500008500,CDM,637,RC,574012074,NDC,999,EAPG,,,,outpatient,facility,120,UN,25.05,25.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHARCOAL/WATER 25 GM/120 ML,2500008510,CDM,637,RC,574052174,NDC,,,,,,inpatient,facility,120,UN,25.05,25.05,2,25.05,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.55,,,percent of total billed charges,,,,,,,,,25.05,,,percent of total billed charges,,,13.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,13.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.59,,,percent of total billed charges,,
CHARCOAL/WATER 25 GM/120 ML,2500008510,CDM,637,RC,574052174,NDC,,,,,,outpatient,facility,120,UN,25.05,25.05,2,618.77,,14.63,,,percent of total billed charges,,,4.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,25.05,,,percent of total billed charges,,,22.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,22.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,22.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22.55,,,percent of total billed charges,,,,,,,,,25.05,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,13.53,,,percent of total billed charges,,,13.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.06,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,9.49,,,percent of total billed charges,,,12.97,,,percent of total billed charges,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,9.27,,,percent of total billed charges,,,9.27,,,percent of total billed charges,,,25.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,25.05,,,fee schedule,,,23.3,,,percent of total billed charges,,,,,,,,,,,,,,,23.3,,,percent of total billed charges,,,23.3,,,percent of total billed charges,,,23.3,,,percent of total billed charges,,,18.79,,,percent of total billed charges,,,25.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.59,,,percent of total billed charges,,
CHARCOAL/WATER 25 GM/120 ML,2500008510,CDM,637,RC,574052174,NDC,999,EAPG,,,,outpatient,facility,120,UN,25.05,25.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORDIAZEPOXIDE 5 MG CAP,2500008575,CDM,637,RC,555015802,NDC,,,,,,inpatient,facility,5,UN,1.15,1.15,0.09,1.15,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,,,,,,,1.15,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,
CHLORDIAZEPOXIDE 5 MG CAP,2500008575,CDM,637,RC,555015802,NDC,,,,,,outpatient,facility,5,UN,1.15,1.15,0.09,618.77,,0.67,,,percent of total billed charges,,,0.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.15,,,percent of total billed charges,,,1.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.03,,,percent of total billed charges,,,,,,,,,1.15,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,1.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,1.15,,,fee schedule,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,1.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.81,,,percent of total billed charges,,
CHLORDIAZEPOXIDE 5 MG CAP,2500008575,CDM,637,RC,555015802,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.15,1.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORHEXIDINE 0.12  15 ML UDC,2500008590,CDM,637,RC,6933913815,NDC,,,,,,inpatient,facility,15,UN,7.89,7.89,0.63,7.89,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.1,,,percent of total billed charges,,,,,,,,,7.89,,,percent of total billed charges,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,
CHLORHEXIDINE 0.12  15 ML UDC,2500008590,CDM,637,RC,6933913815,NDC,,,,,,outpatient,facility,15,UN,7.89,7.89,0.63,618.77,,4.61,,,percent of total billed charges,,,1.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.89,,,percent of total billed charges,,,6.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.1,,,percent of total billed charges,,,,,,,,,7.89,,,percent of total billed charges,,,5.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.06,,,percent of total billed charges,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.11,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.92,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,7.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.63,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,7.89,,,fee schedule,,,7.34,,,percent of total billed charges,,,,,,,,,,,,,,,7.34,,,percent of total billed charges,,,7.34,,,percent of total billed charges,,,7.34,,,percent of total billed charges,,,5.92,,,percent of total billed charges,,,7.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.89,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.54,,,percent of total billed charges,,
CHLORHEXIDINE 0.12  15 ML UDC,2500008590,CDM,637,RC,6933913815,NDC,999,EAPG,,,,outpatient,facility,15,UN,7.89,7.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORHEXIDINE  4  120 ML,2500008604,CDM,637,RC,234057504,NDC,,,,,,inpatient,facility,118,UN,5.6,5.6,0.45,5.6,,,,,,,,,,,,,,5.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.04,,,percent of total billed charges,,,,,,,,,5.6,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.6,,,percent of total billed charges,,,,,,,,,,,,,,,5.6,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,5.6,,,percent of total billed charges,,,5.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,
CHLORHEXIDINE  4  120 ML,2500008604,CDM,637,RC,234057504,NDC,,,,,,outpatient,facility,118,UN,5.6,5.6,0.45,618.77,,3.27,,,percent of total billed charges,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.6,,,percent of total billed charges,,,4.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.04,,,percent of total billed charges,,,,,,,,,5.6,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,,,,,,,,,,,,,,3.02,,,percent of total billed charges,,,3.02,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,5.6,,,percent of total billed charges,,,5.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.07,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,5.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.45,,,percent of total billed charges,,,5.6,,,percent of total billed charges,,,5.6,,,percent of total billed charges,,,,,,,,,,,,,,,5.6,,,percent of total billed charges,,,5.6,,,percent of total billed charges,,,,,,,,,5.6,,,fee schedule,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,4.2,,,percent of total billed charges,,,5.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.6,,,percent of total billed charges,,,5.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.93,,,percent of total billed charges,,
CHLORHEXIDINE  4  120 ML,2500008604,CDM,637,RC,234057504,NDC,999,EAPG,,,,outpatient,facility,118,UN,5.6,5.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORTHALIDONE 25 MG TAB,2500008702,CDM,637,RC,4359871901,NDC,,,,,,inpatient,facility,25,UN,3.99,3.99,0.32,3.99,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.59,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,
CHLORTHALIDONE 25 MG TAB,2500008702,CDM,637,RC,4359871901,NDC,,,,,,outpatient,facility,25,UN,3.99,3.99,0.32,618.77,,2.33,,,percent of total billed charges,,,0.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.99,,,percent of total billed charges,,,3.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.59,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.48,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,3.99,,,fee schedule,,,3.71,,,percent of total billed charges,,,,,,,,,,,,,,,3.71,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,3.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.8,,,percent of total billed charges,,
CHLORTHALIDONE 25 MG TAB,2500008702,CDM,637,RC,4359871901,NDC,999,EAPG,,,,outpatient,facility,25,UN,3.99,3.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHOLESTYRAMINE 4 GM PKT,2500008740,CDM,637,RC,4988446565,NDC,,,,,,inpatient,facility,4,UN,11.12,11.12,0.89,11.12,,,,,,,,,,,,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.01,,,percent of total billed charges,,,,,,,,,11.12,,,percent of total billed charges,,,6.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,11.12,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,11.12,,,percent of total billed charges,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.81,,,percent of total billed charges,,
CHOLESTYRAMINE 4 GM PKT,2500008740,CDM,637,RC,4988446565,NDC,,,,,,outpatient,facility,4,UN,11.12,11.12,0.89,618.77,,6.49,,,percent of total billed charges,,,2.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.12,,,percent of total billed charges,,,9.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,9.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,9.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.01,,,percent of total billed charges,,,,,,,,,11.12,,,percent of total billed charges,,,7.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.54,,,percent of total billed charges,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,6,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,11.12,,,percent of total billed charges,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,5.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.11,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,11.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.89,,,percent of total billed charges,,,11.12,,,percent of total billed charges,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,11.12,,,percent of total billed charges,,,11.12,,,percent of total billed charges,,,,,,,,,11.12,,,fee schedule,,,10.34,,,percent of total billed charges,,,,,,,,,,,,,,,10.34,,,percent of total billed charges,,,10.34,,,percent of total billed charges,,,10.34,,,percent of total billed charges,,,8.34,,,percent of total billed charges,,,11.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.12,,,percent of total billed charges,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.81,,,percent of total billed charges,,
CHOLESTYRAMINE 4 GM PKT,2500008740,CDM,637,RC,4988446565,NDC,999,EAPG,,,,outpatient,facility,4,UN,11.12,11.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CILOSTAZOL 50 MG TAB,2500008812,CDM,637,RC,5026817615,NDC,,,,,,inpatient,facility,50,UN,7.36,7.36,0.59,7.36,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.62,,,percent of total billed charges,,,,,,,,,7.36,,,percent of total billed charges,,,4.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,
CILOSTAZOL 50 MG TAB,2500008812,CDM,637,RC,5026817615,NDC,,,,,,outpatient,facility,50,UN,7.36,7.36,0.59,618.77,,4.3,,,percent of total billed charges,,,1.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.36,,,percent of total billed charges,,,6.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.62,,,percent of total billed charges,,,,,,,,,7.36,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.65,,,percent of total billed charges,,,,,,,,,,,,,,,3.97,,,percent of total billed charges,,,3.97,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.84,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.59,,,percent of total billed charges,,,2.79,,,percent of total billed charges,,,3.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.72,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,7.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,,,,,,,7.36,,,fee schedule,,,6.85,,,percent of total billed charges,,,,,,,,,,,,,,,6.85,,,percent of total billed charges,,,6.85,,,percent of total billed charges,,,6.85,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,7.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.36,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.17,,,percent of total billed charges,,
CILOSTAZOL 50 MG TAB,2500008812,CDM,637,RC,5026817615,NDC,999,EAPG,,,,outpatient,facility,50,UN,7.36,7.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CIPROFLOXACIN 250 MG TAB,2500008831,CDM,637,RC,6213530801,NDC,,,,,,inpatient,facility,250,UN,14.65,14.65,1.17,14.65,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.19,,,percent of total billed charges,,,,,,,,,14.65,,,percent of total billed charges,,,8.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.29,,,percent of total billed charges,,
CIPROFLOXACIN 250 MG TAB,2500008831,CDM,637,RC,6213530801,NDC,,,,,,outpatient,facility,250,UN,14.65,14.65,1.17,618.77,,8.56,,,percent of total billed charges,,,2.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.65,,,percent of total billed charges,,,12.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.19,,,percent of total billed charges,,,,,,,,,14.65,,,percent of total billed charges,,,9.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,7.91,,,percent of total billed charges,,,7.91,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.13,,,percent of total billed charges,,,5.55,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.42,,,percent of total billed charges,,,5.42,,,percent of total billed charges,,,14.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.17,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,14.65,,,fee schedule,,,13.63,,,percent of total billed charges,,,,,,,,,,,,,,,13.63,,,percent of total billed charges,,,13.63,,,percent of total billed charges,,,13.63,,,percent of total billed charges,,,10.99,,,percent of total billed charges,,,14.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.65,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.33,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.29,,,percent of total billed charges,,
CIPROFLOXACIN 250 MG TAB,2500008831,CDM,637,RC,6213530801,NDC,999,EAPG,,,,outpatient,facility,250,UN,14.65,14.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CIPROFLOXACIN 500 MG TAB,2500008832,CDM,637,RC,6213530901,NDC,,,,,,inpatient,facility,500,UN,24.19,24.19,1.94,24.19,,,,,,,,,,,,,,24.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.77,,,percent of total billed charges,,,,,,,,,24.19,,,percent of total billed charges,,,13.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.19,,,percent of total billed charges,,,,,,,,,,,,,,,24.19,,,percent of total billed charges,,,12.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,24.19,,,percent of total billed charges,,,24.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.99,,,percent of total billed charges,,
CIPROFLOXACIN 500 MG TAB,2500008832,CDM,637,RC,6213530901,NDC,,,,,,outpatient,facility,500,UN,24.19,24.19,1.94,618.77,,14.13,,,percent of total billed charges,,,4.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,24.19,,,percent of total billed charges,,,21.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,21.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,21.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,24.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,21.77,,,percent of total billed charges,,,,,,,,,24.19,,,percent of total billed charges,,,16.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.58,,,percent of total billed charges,,,,,,,,,,,,,,,13.06,,,percent of total billed charges,,,13.06,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,24.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.61,,,percent of total billed charges,,,24.19,,,percent of total billed charges,,,24.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,12.53,,,percent of total billed charges,,,,,,,,,,,,,,,4.84,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.95,,,percent of total billed charges,,,8.95,,,percent of total billed charges,,,24.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.94,,,percent of total billed charges,,,24.19,,,percent of total billed charges,,,24.19,,,percent of total billed charges,,,,,,,,,,,,,,,24.19,,,percent of total billed charges,,,24.19,,,percent of total billed charges,,,,,,,,,24.19,,,fee schedule,,,22.5,,,percent of total billed charges,,,,,,,,,,,,,,,22.5,,,percent of total billed charges,,,22.5,,,percent of total billed charges,,,22.5,,,percent of total billed charges,,,18.14,,,percent of total billed charges,,,24.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,24.19,,,percent of total billed charges,,,24.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,16.99,,,percent of total billed charges,,
CIPROFLOXACIN 500 MG TAB,2500008832,CDM,637,RC,6213530901,NDC,999,EAPG,,,,outpatient,facility,500,UN,24.19,24.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CIPROFLOXACIN 0.3  OPH 2.5 ML,2500008835,CDM,637,RC,6931530802,NDC,,,,,,inpatient,facility,2.5,UN,34.65,34.65,2.77,34.65,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.18,,,percent of total billed charges,,,,,,,,,34.65,,,percent of total billed charges,,,19.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,18.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.33,,,percent of total billed charges,,
CIPROFLOXACIN 0.3  OPH 2.5 ML,2500008835,CDM,637,RC,6931530802,NDC,,,,,,outpatient,facility,2.5,UN,34.65,34.65,2.77,618.77,,20.24,,,percent of total billed charges,,,6.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,34.65,,,percent of total billed charges,,,30.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,30.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,30.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,12.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,31.18,,,percent of total billed charges,,,,,,,,,34.65,,,percent of total billed charges,,,23.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.61,,,percent of total billed charges,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.07,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.33,,,percent of total billed charges,,,13.13,,,percent of total billed charges,,,17.95,,,percent of total billed charges,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,12.82,,,percent of total billed charges,,,12.82,,,percent of total billed charges,,,34.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,34.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,34.65,,,fee schedule,,,32.23,,,percent of total billed charges,,,,,,,,,,,,,,,32.23,,,percent of total billed charges,,,32.23,,,percent of total billed charges,,,32.23,,,percent of total billed charges,,,25.99,,,percent of total billed charges,,,34.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,24.33,,,percent of total billed charges,,
CIPROFLOXACIN 0.3  OPH 2.5 ML,2500008835,CDM,637,RC,6931530802,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,34.65,34.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CIPROFLOXACN 0.3  OPH SOL 5 ML,2500008837,CDM,637,RC,6931530805,NDC,,,,,,inpatient,facility,5,UN,46.2,46.2,3.7,46.2,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.58,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,25.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,24.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.44,,,percent of total billed charges,,
CIPROFLOXACN 0.3  OPH SOL 5 ML,2500008837,CDM,637,RC,6931530805,NDC,,,,,,outpatient,facility,5,UN,46.2,46.2,3.7,618.77,,26.98,,,percent of total billed charges,,,9.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,46.2,,,percent of total billed charges,,,40.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,40.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,40.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,41.58,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,31.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.48,,,percent of total billed charges,,,,,,,,,,,,,,,24.95,,,percent of total billed charges,,,24.95,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.09,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.11,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,17.09,,,percent of total billed charges,,,17.09,,,percent of total billed charges,,,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,46.2,,,fee schedule,,,42.98,,,percent of total billed charges,,,,,,,,,,,,,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,46.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,32.44,,,percent of total billed charges,,
CIPROFLOXACN 0.3  OPH SOL 5 ML,2500008837,CDM,637,RC,6931530805,NDC,999,EAPG,,,,outpatient,facility,5,UN,46.2,46.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CISATRACURIUM BESY 200 MG/20ML,2500008862,CDM,250,RC,J3490,HCPCS,7006915110,NDC,,,,inpatient,facility,20,UN,1071.18,1071.18,85.69,1071.18,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,964.06,,,percent of total billed charges,,,,,,,,,1071.18,,,percent of total billed charges,,,593.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,977.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,558.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.69,,,percent of total billed charges,,,1071.18,,,percent of total billed charges,,,1071.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,752.18,,,percent of total billed charges,,
CISATRACURIUM BESY 200 MG/20ML,2500008862,CDM,250,RC,J3490,HCPCS,7006915110,NDC,,,,outpatient,facility,20,UN,1071.18,1071.18,1.2,1071.18,,625.57,,,percent of total billed charges,,,208.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1071.18,,,percent of total billed charges,,,943.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,943.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,943.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,392.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,964.06,,,percent of total billed charges,,,,,,,,,1071.18,,,percent of total billed charges,,,725.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.67,,,percent of total billed charges,,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,1071.18,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1071.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,558.51,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,814.1,,,percent of total billed charges,,,405.76,,,percent of total billed charges,,,554.76,,,percent of total billed charges,,,,,,,,,,,,,,,214.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,1071.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1071.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,85.69,,,percent of total billed charges,,,1071.18,,,percent of total billed charges,,,1071.18,,,percent of total billed charges,,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,1071.18,,,percent of total billed charges,,,,,,,,,1071.18,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,803.38,,,percent of total billed charges,,,1071.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1071.18,,,percent of total billed charges,,,1071.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,535.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,752.18,,,percent of total billed charges,,
CISATRACURIUM BESY 200 MG/20ML,2500008862,CDM,250,RC,J3490,HCPCS,7006915110,NDC,435,EAPG,,outpatient,facility,20,UN,1071.18,1071.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CITRIC ACID/ SOD CIT 15 ML UDC,2500008900,CDM,637,RC,121059500,NDC,,,,,,inpatient,facility,15,UN,16.83,16.83,1.35,16.83,,,,,,,,,,,,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,,,,,,,16.83,,,percent of total billed charges,,,9.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,16.83,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,16.83,,,percent of total billed charges,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.82,,,percent of total billed charges,,
CITRIC ACID/ SOD CIT 15 ML UDC,2500008900,CDM,637,RC,121059500,NDC,,,,,,outpatient,facility,15,UN,16.83,16.83,1.35,618.77,,9.83,,,percent of total billed charges,,,3.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.83,,,percent of total billed charges,,,14.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,14.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,14.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,15.15,,,percent of total billed charges,,,,,,,,,16.83,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,9.09,,,percent of total billed charges,,,9.09,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,16.83,,,percent of total billed charges,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.79,,,percent of total billed charges,,,6.38,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,16.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.35,,,percent of total billed charges,,,16.83,,,percent of total billed charges,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,16.83,,,percent of total billed charges,,,16.83,,,percent of total billed charges,,,,,,,,,16.83,,,fee schedule,,,15.66,,,percent of total billed charges,,,,,,,,,,,,,,,15.66,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,12.62,,,percent of total billed charges,,,16.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.83,,,percent of total billed charges,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.82,,,percent of total billed charges,,
CITRIC ACID/ SOD CIT 15 ML UDC,2500008900,CDM,637,RC,121059500,NDC,999,EAPG,,,,outpatient,facility,15,UN,16.83,16.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLARITHROMYCIN 250 MG TAB,2500008912,CDM,637,RC,781196160,NDC,,,,,,inpatient,facility,250,UN,19.86,19.86,1.59,19.86,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.87,,,percent of total billed charges,,,,,,,,,19.86,,,percent of total billed charges,,,10.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,
CLARITHROMYCIN 250 MG TAB,2500008912,CDM,637,RC,781196160,NDC,,,,,,outpatient,facility,250,UN,19.86,19.86,1.59,618.77,,11.6,,,percent of total billed charges,,,3.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,19.86,,,percent of total billed charges,,,17.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,17.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,17.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,17.87,,,percent of total billed charges,,,,,,,,,19.86,,,percent of total billed charges,,,13.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.25,,,percent of total billed charges,,,,,,,,,,,,,,,10.72,,,percent of total billed charges,,,10.72,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.09,,,percent of total billed charges,,,7.52,,,percent of total billed charges,,,10.29,,,percent of total billed charges,,,,,,,,,,,,,,,3.97,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.35,,,percent of total billed charges,,,7.35,,,percent of total billed charges,,,19.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.59,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,,,,,,,19.86,,,fee schedule,,,18.47,,,percent of total billed charges,,,,,,,,,,,,,,,18.47,,,percent of total billed charges,,,18.47,,,percent of total billed charges,,,18.47,,,percent of total billed charges,,,14.89,,,percent of total billed charges,,,19.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,19.86,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,13.95,,,percent of total billed charges,,
CLARITHROMYCIN 250 MG TAB,2500008912,CDM,637,RC,781196160,NDC,999,EAPG,,,,outpatient,facility,250,UN,19.86,19.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLINDAMYCIN HCL 150 MG CAP,2500008930,CDM,637,RC,904595961,NDC,,,,,,inpatient,facility,150,UN,1.09,1.09,0.09,1.09,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,
CLINDAMYCIN HCL 150 MG CAP,2500008930,CDM,637,RC,904595961,NDC,,,,,,outpatient,facility,150,UN,1.09,1.09,0.09,618.77,,0.64,,,percent of total billed charges,,,0.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.09,,,percent of total billed charges,,,0.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.98,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,1.09,,,fee schedule,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,1.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.77,,,percent of total billed charges,,
CLINDAMYCIN HCL 150 MG CAP,2500008930,CDM,637,RC,904595961,NDC,999,EAPG,,,,outpatient,facility,150,UN,1.09,1.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOBETASOL 0.05  OINT 30 GM,2500008965,CDM,637,RC,5167212592,NDC,,,,,,inpatient,facility,30,UN,857.18,857.18,68.57,857.18,,,,,,,,,,,,,,857.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,771.46,,,percent of total billed charges,,,,,,,,,857.18,,,percent of total billed charges,,,474.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,782.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,857.18,,,percent of total billed charges,,,,,,,,,,,,,,,857.18,,,percent of total billed charges,,,446.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.57,,,percent of total billed charges,,,857.18,,,percent of total billed charges,,,857.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,857.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,601.91,,,percent of total billed charges,,
CLOBETASOL 0.05  OINT 30 GM,2500008965,CDM,637,RC,5167212592,NDC,,,,,,outpatient,facility,30,UN,857.18,857.18,68.57,857.18,,500.59,,,percent of total billed charges,,,167.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,857.18,,,percent of total billed charges,,,754.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,754.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,754.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,857.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,313.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,771.46,,,percent of total billed charges,,,,,,,,,857.18,,,percent of total billed charges,,,580.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,658.31,,,percent of total billed charges,,,,,,,,,,,,,,,462.88,,,percent of total billed charges,,,462.88,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,857.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,446.93,,,percent of total billed charges,,,857.18,,,percent of total billed charges,,,857.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.46,,,percent of total billed charges,,,324.7,,,percent of total billed charges,,,443.93,,,percent of total billed charges,,,,,,,,,,,,,,,171.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,317.16,,,percent of total billed charges,,,317.16,,,percent of total billed charges,,,857.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,857.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,68.57,,,percent of total billed charges,,,857.18,,,percent of total billed charges,,,857.18,,,percent of total billed charges,,,,,,,,,,,,,,,857.18,,,percent of total billed charges,,,857.18,,,percent of total billed charges,,,,,,,,,857.18,,,fee schedule,,,797.35,,,percent of total billed charges,,,,,,,,,,,,,,,797.35,,,percent of total billed charges,,,797.35,,,percent of total billed charges,,,797.35,,,percent of total billed charges,,,642.88,,,percent of total billed charges,,,857.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,857.18,,,percent of total billed charges,,,857.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,428.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,601.91,,,percent of total billed charges,,
CLOBETASOL 0.05  OINT 30 GM,2500008965,CDM,637,RC,5167212592,NDC,999,EAPG,,,,outpatient,facility,30,UN,857.18,857.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOMIPRAMINE HCL 25 MG CAP,2500009000,CDM,637,RC,4257134230,NDC,,,,,,inpatient,facility,25,UN,37.09,37.09,2.97,37.09,,,,,,,,,,,,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.38,,,percent of total billed charges,,,,,,,,,37.09,,,percent of total billed charges,,,20.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,37.09,,,percent of total billed charges,,,19.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.04,,,percent of total billed charges,,
CLOMIPRAMINE HCL 25 MG CAP,2500009000,CDM,637,RC,4257134230,NDC,,,,,,outpatient,facility,25,UN,37.09,37.09,2.97,618.77,,21.66,,,percent of total billed charges,,,7.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,37.09,,,percent of total billed charges,,,32.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,32.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,32.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,13.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,33.38,,,percent of total billed charges,,,,,,,,,37.09,,,percent of total billed charges,,,25.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.49,,,percent of total billed charges,,,,,,,,,,,,,,,20.03,,,percent of total billed charges,,,20.03,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.34,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.19,,,percent of total billed charges,,,14.05,,,percent of total billed charges,,,19.21,,,percent of total billed charges,,,,,,,,,,,,,,,7.42,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,37.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,37.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.97,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,37.09,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,,,,,,,37.09,,,fee schedule,,,34.5,,,percent of total billed charges,,,,,,,,,,,,,,,34.5,,,percent of total billed charges,,,34.5,,,percent of total billed charges,,,34.5,,,percent of total billed charges,,,27.82,,,percent of total billed charges,,,37.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,37.09,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,26.04,,,percent of total billed charges,,
CLOMIPRAMINE HCL 25 MG CAP,2500009000,CDM,637,RC,4257134230,NDC,999,EAPG,,,,outpatient,facility,25,UN,37.09,37.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLONAZEPAM 0.5 MG TAB,2500009010,CDM,637,RC,4354740610,NDC,,,,,,inpatient,facility,0.5,UN,2.48,2.48,0.2,2.48,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,,,,2.48,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,
CLONAZEPAM 0.5 MG TAB,2500009010,CDM,637,RC,4354740610,NDC,,,,,,outpatient,facility,0.5,UN,2.48,2.48,0.2,618.77,,1.45,,,percent of total billed charges,,,0.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.48,,,percent of total billed charges,,,2.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.23,,,percent of total billed charges,,,,,,,,,2.48,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,2.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,2.48,,,fee schedule,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,2.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.74,,,percent of total billed charges,,
CLONAZEPAM 0.5 MG TAB,2500009010,CDM,637,RC,4354740610,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,2.48,2.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLONAZEPAM 1 MG TAB,2500009012,CDM,637,RC,4354740710,NDC,,,,,,inpatient,facility,1,UN,2.84,2.84,0.23,2.84,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,,,,,,,2.84,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,
CLONAZEPAM 1 MG TAB,2500009012,CDM,637,RC,4354740710,NDC,,,,,,outpatient,facility,1,UN,2.84,2.84,0.23,618.77,,1.66,,,percent of total billed charges,,,0.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.84,,,percent of total billed charges,,,2.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.56,,,percent of total billed charges,,,,,,,,,2.84,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,2.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,2.84,,,fee schedule,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,2.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.99,,,percent of total billed charges,,
CLONAZEPAM 1 MG TAB,2500009012,CDM,637,RC,4354740710,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.84,2.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLONIDINE HCL 0.1 MG TAB,2500009020,CDM,637,RC,228212710,NDC,,,,,,inpatient,facility,0.1,UN,0.85,0.85,0.07,0.85,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,,,,,,,0.85,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,
CLONIDINE HCL 0.1 MG TAB,2500009020,CDM,637,RC,228212710,NDC,,,,,,outpatient,facility,0.1,UN,0.85,0.85,0.07,618.77,,0.5,,,percent of total billed charges,,,0.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.85,,,percent of total billed charges,,,0.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.77,,,percent of total billed charges,,,,,,,,,0.85,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,0.85,,,fee schedule,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.85,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.6,,,percent of total billed charges,,
CLONIDINE HCL 0.1 MG TAB,2500009020,CDM,637,RC,228212710,NDC,999,EAPG,,,,outpatient,facility,0.1,UN,0.85,0.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLONIDINE HCL 0.2 MG TAB,2500009022,CDM,637,RC,6068712401,NDC,,,,,,inpatient,facility,0.2,UN,1.22,1.22,0.1,1.22,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,
CLONIDINE HCL 0.2 MG TAB,2500009022,CDM,637,RC,6068712401,NDC,,,,,,outpatient,facility,0.2,UN,1.22,1.22,0.1,618.77,,0.71,,,percent of total billed charges,,,0.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.22,,,percent of total billed charges,,,1.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.1,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.45,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,1.22,,,fee schedule,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,1.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.86,,,percent of total billed charges,,
CLONIDINE HCL 0.2 MG TAB,2500009022,CDM,637,RC,6068712401,NDC,999,EAPG,,,,outpatient,facility,0.2,UN,1.22,1.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLONIDINE-TTS 0.1MG/24HR PATCH,2500009030,CDM,637,RC,378087199,NDC,,,,,,inpatient,facility,1,UN,109.3,109.3,8.74,109.3,,,,,,,,,,,,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.37,,,percent of total billed charges,,,,,,,,,109.3,,,percent of total billed charges,,,60.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,109.3,,,percent of total billed charges,,,56.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.74,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.75,,,percent of total billed charges,,
CLONIDINE-TTS 0.1MG/24HR PATCH,2500009030,CDM,637,RC,378087199,NDC,,,,,,outpatient,facility,1,UN,109.3,109.3,8.74,618.77,,63.83,,,percent of total billed charges,,,21.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,109.3,,,percent of total billed charges,,,96.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,96.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,96.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,40,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,98.37,,,percent of total billed charges,,,,,,,,,109.3,,,percent of total billed charges,,,74.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.94,,,percent of total billed charges,,,,,,,,,,,,,,,59.02,,,percent of total billed charges,,,59.02,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.99,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.07,,,percent of total billed charges,,,41.4,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,,,,,,,,,,,,,21.86,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,40.44,,,percent of total billed charges,,,40.44,,,percent of total billed charges,,,109.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,109.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.74,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,109.3,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,,,,,,,109.3,,,fee schedule,,,101.67,,,percent of total billed charges,,,,,,,,,,,,,,,101.67,,,percent of total billed charges,,,101.67,,,percent of total billed charges,,,101.67,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,109.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,109.3,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,76.75,,,percent of total billed charges,,
CLONIDINE-TTS 0.1MG/24HR PATCH,2500009030,CDM,637,RC,378087199,NDC,999,EAPG,,,,outpatient,facility,1,UN,109.3,109.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLONIDINE-TTS 0.2MG/24HR PATCH,2500009032,CDM,637,RC,378087299,NDC,,,,,,inpatient,facility,1,UN,184.04,184.04,14.72,184.04,,,,,,,,,,,,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.64,,,percent of total billed charges,,,,,,,,,184.04,,,percent of total billed charges,,,101.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,184.04,,,percent of total billed charges,,,95.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.72,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.23,,,percent of total billed charges,,
CLONIDINE-TTS 0.2MG/24HR PATCH,2500009032,CDM,637,RC,378087299,NDC,,,,,,outpatient,facility,1,UN,184.04,184.04,14.72,618.77,,107.48,,,percent of total billed charges,,,35.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,184.04,,,percent of total billed charges,,,162.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,162.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,162.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,67.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,165.64,,,percent of total billed charges,,,,,,,,,184.04,,,percent of total billed charges,,,124.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.34,,,percent of total billed charges,,,,,,,,,,,,,,,99.38,,,percent of total billed charges,,,99.38,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.96,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.87,,,percent of total billed charges,,,69.71,,,percent of total billed charges,,,95.31,,,percent of total billed charges,,,,,,,,,,,,,,,36.81,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,68.09,,,percent of total billed charges,,,68.09,,,percent of total billed charges,,,184.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,184.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.72,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,184.04,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,,,,,,,184.04,,,fee schedule,,,171.19,,,percent of total billed charges,,,,,,,,,,,,,,,171.19,,,percent of total billed charges,,,171.19,,,percent of total billed charges,,,171.19,,,percent of total billed charges,,,138.03,,,percent of total billed charges,,,184.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,184.04,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,129.23,,,percent of total billed charges,,
CLONIDINE-TTS 0.2MG/24HR PATCH,2500009032,CDM,637,RC,378087299,NDC,999,EAPG,,,,outpatient,facility,1,UN,184.04,184.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLONIDINE-TTS 0.3MG/24HR PATCH,2500009033,CDM,637,RC,378087399,NDC,,,,,,inpatient,facility,1,UN,255.29,255.29,20.42,255.29,,,,,,,,,,,,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,229.76,,,percent of total billed charges,,,,,,,,,255.29,,,percent of total billed charges,,,141.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,255.29,,,percent of total billed charges,,,133.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.42,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.26,,,percent of total billed charges,,
CLONIDINE-TTS 0.3MG/24HR PATCH,2500009033,CDM,637,RC,378087399,NDC,,,,,,outpatient,facility,1,UN,255.29,255.29,20.42,618.77,,149.09,,,percent of total billed charges,,,49.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,255.29,,,percent of total billed charges,,,224.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,224.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,224.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,93.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,229.76,,,percent of total billed charges,,,,,,,,,255.29,,,percent of total billed charges,,,172.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.06,,,percent of total billed charges,,,,,,,,,,,,,,,137.86,,,percent of total billed charges,,,137.86,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,133.11,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.02,,,percent of total billed charges,,,96.7,,,percent of total billed charges,,,132.21,,,percent of total billed charges,,,,,,,,,,,,,,,51.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,94.46,,,percent of total billed charges,,,94.46,,,percent of total billed charges,,,255.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,255.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.42,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,255.29,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,,,,,,,255.29,,,fee schedule,,,237.47,,,percent of total billed charges,,,,,,,,,,,,,,,237.47,,,percent of total billed charges,,,237.47,,,percent of total billed charges,,,237.47,,,percent of total billed charges,,,191.47,,,percent of total billed charges,,,255.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,255.29,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,179.26,,,percent of total billed charges,,
CLONIDINE-TTS 0.3MG/24HR PATCH,2500009033,CDM,637,RC,378087399,NDC,999,EAPG,,,,outpatient,facility,1,UN,255.29,255.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOPIDOGREL BISULF 75 MG TAB,2500009040,CDM,637,RC,904629461,NDC,,,,,,inpatient,facility,75,UN,0.79,0.79,0.06,0.79,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,
CLOPIDOGREL BISULF 75 MG TAB,2500009040,CDM,637,RC,904629461,NDC,,,,,,outpatient,facility,75,UN,0.79,0.79,0.06,618.77,,0.46,,,percent of total billed charges,,,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.71,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,0.79,,,fee schedule,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.55,,,percent of total billed charges,,
CLOPIDOGREL BISULF 75 MG TAB,2500009040,CDM,637,RC,904629461,NDC,999,EAPG,,,,outpatient,facility,75,UN,0.79,0.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOPIDOGREL 300 MG TAB,2500009045,CDM,637,RC,904646707,NDC,,,,,,inpatient,facility,300,UN,43.86,43.86,3.51,43.86,,,,,,,,,,,,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,43.86,,,percent of total billed charges,,,24.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,43.86,,,percent of total billed charges,,,22.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.8,,,percent of total billed charges,,
CLOPIDOGREL 300 MG TAB,2500009045,CDM,637,RC,904646707,NDC,,,,,,outpatient,facility,300,UN,43.86,43.86,3.51,618.77,,25.61,,,percent of total billed charges,,,8.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,43.86,,,percent of total billed charges,,,38.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,38.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,38.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,39.47,,,percent of total billed charges,,,,,,,,,43.86,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.68,,,percent of total billed charges,,,,,,,,,,,,,,,23.68,,,percent of total billed charges,,,23.68,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.87,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.33,,,percent of total billed charges,,,16.61,,,percent of total billed charges,,,22.72,,,percent of total billed charges,,,,,,,,,,,,,,,8.77,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,16.23,,,percent of total billed charges,,,16.23,,,percent of total billed charges,,,43.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.51,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,43.86,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,,,,,,,43.86,,,fee schedule,,,40.8,,,percent of total billed charges,,,,,,,,,,,,,,,40.8,,,percent of total billed charges,,,40.8,,,percent of total billed charges,,,40.8,,,percent of total billed charges,,,32.89,,,percent of total billed charges,,,43.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,43.86,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,30.8,,,percent of total billed charges,,
CLOPIDOGREL 300 MG TAB,2500009045,CDM,637,RC,904646707,NDC,999,EAPG,,,,outpatient,facility,300,UN,43.86,43.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOTRIMAZOLE 1  CR 30 GM,2500009061,CDM,637,RC,4580243411,NDC,,,,,,inpatient,facility,30,UN,10.55,10.55,0.84,10.55,,,,,,,,,,,,,,10.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,10.55,,,percent of total billed charges,,,5.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.55,,,percent of total billed charges,,,,,,,,,,,,,,,10.55,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,10.55,,,percent of total billed charges,,,10.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.41,,,percent of total billed charges,,
CLOTRIMAZOLE 1  CR 30 GM,2500009061,CDM,637,RC,4580243411,NDC,,,,,,outpatient,facility,30,UN,10.55,10.55,0.84,618.77,,6.16,,,percent of total billed charges,,,2.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.55,,,percent of total billed charges,,,9.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,9.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,9.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.5,,,percent of total billed charges,,,,,,,,,10.55,,,percent of total billed charges,,,7.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.1,,,percent of total billed charges,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,5.7,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,10.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.5,,,percent of total billed charges,,,10.55,,,percent of total billed charges,,,10.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.02,,,percent of total billed charges,,,4,,,percent of total billed charges,,,5.46,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.9,,,percent of total billed charges,,,3.9,,,percent of total billed charges,,,10.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.84,,,percent of total billed charges,,,10.55,,,percent of total billed charges,,,10.55,,,percent of total billed charges,,,,,,,,,,,,,,,10.55,,,percent of total billed charges,,,10.55,,,percent of total billed charges,,,,,,,,,10.55,,,fee schedule,,,9.81,,,percent of total billed charges,,,,,,,,,,,,,,,9.81,,,percent of total billed charges,,,9.81,,,percent of total billed charges,,,9.81,,,percent of total billed charges,,,7.91,,,percent of total billed charges,,,10.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.55,,,percent of total billed charges,,,10.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.41,,,percent of total billed charges,,
CLOTRIMAZOLE 1  CR 30 GM,2500009061,CDM,637,RC,4580243411,NDC,999,EAPG,,,,outpatient,facility,30,UN,10.55,10.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOTRIMAZOLE 1  VAG CR 45 GM,2500009067,CDM,637,RC,5167220036,NDC,,,,,,inpatient,facility,45,UN,12,12,0.96,12,,,,,,,,,,,,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.8,,,percent of total billed charges,,,,,,,,,12,,,percent of total billed charges,,,6.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,12,,,percent of total billed charges,,,6.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,12,,,percent of total billed charges,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,
CLOTRIMAZOLE 1  VAG CR 45 GM,2500009067,CDM,637,RC,5167220036,NDC,,,,,,outpatient,facility,45,UN,12,12,0.96,618.77,,7.01,,,percent of total billed charges,,,2.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,12,,,percent of total billed charges,,,10.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,10.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,10.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.8,,,percent of total billed charges,,,,,,,,,12,,,percent of total billed charges,,,8.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.22,,,percent of total billed charges,,,,,,,,,,,,,,,6.48,,,percent of total billed charges,,,6.48,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,12,,,percent of total billed charges,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.12,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,6.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.44,,,percent of total billed charges,,,4.44,,,percent of total billed charges,,,12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.96,,,percent of total billed charges,,,12,,,percent of total billed charges,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,12,,,percent of total billed charges,,,12,,,percent of total billed charges,,,,,,,,,12,,,fee schedule,,,11.16,,,percent of total billed charges,,,,,,,,,,,,,,,11.16,,,percent of total billed charges,,,11.16,,,percent of total billed charges,,,11.16,,,percent of total billed charges,,,9,,,percent of total billed charges,,,12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,12,,,percent of total billed charges,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.43,,,percent of total billed charges,,
CLOTRIMAZOLE 1  VAG CR 45 GM,2500009067,CDM,637,RC,5167220036,NDC,999,EAPG,,,,outpatient,facility,45,UN,12,12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOZAPINE 100 MG TAB,2500009100,CDM,637,RC,904708761,NDC,,,,,,inpatient,facility,100,UN,3.1,3.1,0.25,3.1,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.79,,,percent of total billed charges,,,,,,,,,3.1,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,
CLOZAPINE 100 MG TAB,2500009100,CDM,637,RC,904708761,NDC,,,,,,outpatient,facility,100,UN,3.1,3.1,0.25,618.77,,1.81,,,percent of total billed charges,,,0.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.1,,,percent of total billed charges,,,2.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.79,,,percent of total billed charges,,,,,,,,,3.1,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,3.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.25,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,3.1,,,fee schedule,,,2.88,,,percent of total billed charges,,,,,,,,,,,,,,,2.88,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,3.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.18,,,percent of total billed charges,,
CLOZAPINE 100 MG TAB,2500009100,CDM,637,RC,904708761,NDC,999,EAPG,,,,outpatient,facility,100,UN,3.1,3.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOZAPINE 25 MG TAB,2500009103,CDM,637,RC,904708961,NDC,,,,,,inpatient,facility,25,UN,1.18,1.18,0.09,1.18,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,
CLOZAPINE 25 MG TAB,2500009103,CDM,637,RC,904708961,NDC,,,,,,outpatient,facility,25,UN,1.18,1.18,0.09,618.77,,0.69,,,percent of total billed charges,,,0.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.18,,,percent of total billed charges,,,1.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.06,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.44,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,1.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,1.18,,,fee schedule,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,1.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.83,,,percent of total billed charges,,
CLOZAPINE 25 MG TAB,2500009103,CDM,637,RC,904708961,NDC,999,EAPG,,,,outpatient,facility,25,UN,1.18,1.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CODEINE SULF 15 MG TAB,2500009170,CDM,637,RC,54024324,NDC,,,,,,inpatient,facility,15,UN,2.84,2.84,0.23,2.84,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,,,,,,,2.84,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,
CODEINE SULF 15 MG TAB,2500009170,CDM,637,RC,54024324,NDC,,,,,,outpatient,facility,15,UN,2.84,2.84,0.23,618.77,,1.66,,,percent of total billed charges,,,0.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.84,,,percent of total billed charges,,,2.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.56,,,percent of total billed charges,,,,,,,,,2.84,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,2.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,2.84,,,fee schedule,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,2.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.99,,,percent of total billed charges,,
CODEINE SULF 15 MG TAB,2500009170,CDM,637,RC,54024324,NDC,999,EAPG,,,,outpatient,facility,15,UN,2.84,2.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COLCHICINE 0.6 MG TAB,2500009183,CDM,637,RC,7071013513,NDC,,,,,,inpatient,facility,0.6,UN,22.24,22.24,1.78,22.24,,,,,,,,,,,,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.02,,,percent of total billed charges,,,,,,,,,22.24,,,percent of total billed charges,,,12.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,22.24,,,percent of total billed charges,,,11.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.62,,,percent of total billed charges,,
COLCHICINE 0.6 MG TAB,2500009183,CDM,637,RC,7071013513,NDC,,,,,,outpatient,facility,0.6,UN,22.24,22.24,1.78,618.77,,12.99,,,percent of total billed charges,,,4.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,22.24,,,percent of total billed charges,,,19.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,19.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,19.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,20.02,,,percent of total billed charges,,,,,,,,,22.24,,,percent of total billed charges,,,15.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.08,,,percent of total billed charges,,,,,,,,,,,,,,,12.01,,,percent of total billed charges,,,12.01,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.23,,,percent of total billed charges,,,8.23,,,percent of total billed charges,,,22.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.78,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,22.24,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,,,,,,,22.24,,,fee schedule,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,16.68,,,percent of total billed charges,,,22.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,22.24,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,15.62,,,percent of total billed charges,,
COLCHICINE 0.6 MG TAB,2500009183,CDM,637,RC,7071013513,NDC,999,EAPG,,,,outpatient,facility,0.6,UN,22.24,22.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COLLAGENASE OINT 30 GM,2500009213,CDM,637,RC,5048401030,NDC,,,,,,inpatient,facility,30,UN,997.76,997.76,79.82,997.76,,,,,,,,,,,,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,897.98,,,percent of total billed charges,,,,,,,,,997.76,,,percent of total billed charges,,,552.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,997.76,,,percent of total billed charges,,,520.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.82,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,700.63,,,percent of total billed charges,,
COLLAGENASE OINT 30 GM,2500009213,CDM,637,RC,5048401030,NDC,,,,,,outpatient,facility,30,UN,997.76,997.76,79.82,997.76,,582.69,,,percent of total billed charges,,,194.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,997.76,,,percent of total billed charges,,,878.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,878.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,878.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,365.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,897.98,,,percent of total billed charges,,,,,,,,,997.76,,,percent of total billed charges,,,675.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,766.28,,,percent of total billed charges,,,,,,,,,,,,,,,538.79,,,percent of total billed charges,,,538.79,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,520.23,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,758.3,,,percent of total billed charges,,,377.95,,,percent of total billed charges,,,516.74,,,percent of total billed charges,,,,,,,,,,,,,,,199.55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,369.17,,,percent of total billed charges,,,369.17,,,percent of total billed charges,,,997.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,997.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,79.82,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,997.76,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,,,,,,,997.76,,,fee schedule,,,928.12,,,percent of total billed charges,,,,,,,,,,,,,,,928.12,,,percent of total billed charges,,,928.12,,,percent of total billed charges,,,928.12,,,percent of total billed charges,,,748.32,,,percent of total billed charges,,,997.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,997.76,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,700.63,,,percent of total billed charges,,
COLLAGENASE OINT 30 GM,2500009213,CDM,637,RC,5048401030,NDC,999,EAPG,,,,outpatient,facility,30,UN,997.76,997.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CYANOCOBALAMIN 500 MCG TAB,2500009355,CDM,637,RC,7733393710,NDC,,,,,,inpatient,facility,500,UN,1.61,1.61,0.13,1.61,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,
CYANOCOBALAMIN 500 MCG TAB,2500009355,CDM,637,RC,7733393710,NDC,,,,,,outpatient,facility,500,UN,1.61,1.61,0.13,618.77,,0.94,,,percent of total billed charges,,,0.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.61,,,percent of total billed charges,,,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.45,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.6,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,1.61,,,fee schedule,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,1.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.13,,,percent of total billed charges,,
CYANOCOBALAMIN 500 MCG TAB,2500009355,CDM,637,RC,7733393710,NDC,999,EAPG,,,,outpatient,facility,500,UN,1.61,1.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CYCLOBENZAPRINE 10 MG TAB,2500009370,CDM,637,RC,6909784607,NDC,,,,,,inpatient,facility,10,UN,3.83,3.83,0.31,3.83,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.45,,,percent of total billed charges,,,,,,,,,3.83,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.69,,,percent of total billed charges,,
CYCLOBENZAPRINE 10 MG TAB,2500009370,CDM,637,RC,6909784607,NDC,,,,,,outpatient,facility,10,UN,3.83,3.83,0.31,618.77,,2.24,,,percent of total billed charges,,,0.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.83,,,percent of total billed charges,,,3.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.45,,,percent of total billed charges,,,,,,,,,3.83,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,2.07,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,3.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.31,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,3.83,,,fee schedule,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,3.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.69,,,percent of total billed charges,,
CYCLOBENZAPRINE 10 MG TAB,2500009370,CDM,637,RC,6909784607,NDC,999,EAPG,,,,outpatient,facility,10,UN,3.83,3.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CYCLOPENTOLATE 1  OP 2 ML DRPT,2500009386,CDM,637,RC,6131439601,NDC,,,,,,inpatient,facility,2,UN,55.44,55.44,4.44,55.44,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.9,,,percent of total billed charges,,,,,,,,,55.44,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,28.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.93,,,percent of total billed charges,,
CYCLOPENTOLATE 1  OP 2 ML DRPT,2500009386,CDM,637,RC,6131439601,NDC,,,,,,outpatient,facility,2,UN,55.44,55.44,4.44,618.77,,32.38,,,percent of total billed charges,,,10.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,55.44,,,percent of total billed charges,,,48.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,48.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,48.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,20.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,49.9,,,percent of total billed charges,,,,,,,,,55.44,,,percent of total billed charges,,,37.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.58,,,percent of total billed charges,,,,,,,,,,,,,,,29.94,,,percent of total billed charges,,,29.94,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.13,,,percent of total billed charges,,,21,,,percent of total billed charges,,,28.71,,,percent of total billed charges,,,,,,,,,,,,,,,11.09,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,20.51,,,percent of total billed charges,,,20.51,,,percent of total billed charges,,,55.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,55.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,55.44,,,fee schedule,,,51.57,,,percent of total billed charges,,,,,,,,,,,,,,,51.57,,,percent of total billed charges,,,51.57,,,percent of total billed charges,,,51.57,,,percent of total billed charges,,,41.58,,,percent of total billed charges,,,55.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,38.93,,,percent of total billed charges,,
CYCLOPENTOLATE 1  OP 2 ML DRPT,2500009386,CDM,637,RC,6131439601,NDC,999,EAPG,,,,outpatient,facility,2,UN,55.44,55.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CYPROHEPTADINE 4 MG TAB,2500009430,CDM,637,RC,5281721010,NDC,,,,,,inpatient,facility,4,UN,3.53,3.53,0.28,3.53,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.18,,,percent of total billed charges,,,,,,,,,3.53,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,
CYPROHEPTADINE 4 MG TAB,2500009430,CDM,637,RC,5281721010,NDC,,,,,,outpatient,facility,4,UN,3.53,3.53,0.28,618.77,,2.06,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.53,,,percent of total billed charges,,,3.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.18,,,percent of total billed charges,,,,,,,,,3.53,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.31,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,3.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,3.53,,,fee schedule,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,3.28,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,3.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.48,,,percent of total billed charges,,
CYPROHEPTADINE 4 MG TAB,2500009430,CDM,637,RC,5281721010,NDC,999,EAPG,,,,outpatient,facility,4,UN,3.53,3.53,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W-LACTATED RINGERS 500 ML,2500009446,CDM,258,RC,J7121,HCPCS,338012503,NDC,,,,inpatient,facility,500,UN,19.77,19.77,1.58,19.77,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,,,,,,,,19.77,,,percent of total billed charges,,,10.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,,10.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.88,,,percent of total billed charges,,
D5W-LACTATED RINGERS 500 ML,2500009446,CDM,258,RC,J7121,HCPCS,338012503,NDC,,,,outpatient,facility,500,UN,19.77,19.77,1.58,618.77,,11.55,,,percent of total billed charges,,,3.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,19.77,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,17.79,,,percent of total billed charges,,,,,,,,,19.77,,,percent of total billed charges,,,13.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.31,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.03,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,10.24,,,percent of total billed charges,,,,,,,,,,,,,,,3.95,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,19.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.58,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,,,,,,,19.77,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,14.83,,,percent of total billed charges,,,19.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,19.77,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,13.88,,,percent of total billed charges,,
D5W-LACTATED RINGERS 500 ML,2500009446,CDM,258,RC,J7121,HCPCS,338012503,NDC,999,EAPG,,outpatient,facility,500,UN,19.77,19.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHL 0.9 KCL 40MEQ 1000ML,2500009455,CDM,636,RC,J3480,HCPCS,990711609,NDC,,,,inpatient,facility,1000,UN,29.63,29.63,2.37,29.63,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.67,,,percent of total billed charges,,,,,,,,,29.63,,,percent of total billed charges,,,16.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,15.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.81,,,percent of total billed charges,,
SOD CHL 0.9 KCL 40MEQ 1000ML,2500009455,CDM,636,RC,J3480,HCPCS,990711609,NDC,,,,outpatient,facility,1000,UN,29.63,29.63,0.11,618.77,,17.3,,,percent of total billed charges,,,5.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,29.63,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26.67,,,percent of total billed charges,,,,,,,,,29.63,,,percent of total billed charges,,,20.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.45,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.52,,,percent of total billed charges,,,11.22,,,percent of total billed charges,,,15.35,,,percent of total billed charges,,,,,,,,,,,,,,,5.93,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,29.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.37,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,,,,,,,29.63,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,29.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,29.63,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.81,,,percent of total billed charges,,
SOD CHL 0.9 KCL 40MEQ 1000ML,2500009455,CDM,636,RC,J3480,HCPCS,990711609,NDC,999,EAPG,,outpatient,facility,1000,UN,29.63,29.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W KCL 40 MEQ 1000 ML,2500009456,CDM,636,RC,J3480,HCPCS,409790609,NDC,,,,inpatient,facility,1000,UN,9.14,9.14,0.73,9.14,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.23,,,percent of total billed charges,,,,,,,,,9.14,,,percent of total billed charges,,,5.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.42,,,percent of total billed charges,,
D5W KCL 40 MEQ 1000 ML,2500009456,CDM,636,RC,J3480,HCPCS,409790609,NDC,,,,outpatient,facility,1000,UN,9.14,9.14,0.11,618.77,,5.34,,,percent of total billed charges,,,1.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.14,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.23,,,percent of total billed charges,,,,,,,,,9.14,,,percent of total billed charges,,,6.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.95,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,9.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.73,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,9.14,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,9.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.14,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.42,,,percent of total billed charges,,
D5W KCL 40 MEQ 1000 ML,2500009456,CDM,636,RC,J3480,HCPCS,409790609,NDC,999,EAPG,,outpatient,facility,1000,UN,9.14,9.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W KCL 20 MEQ 1000 ML,2500009457,CDM,636,RC,J3480,HCPCS,990790509,NDC,,,,inpatient,facility,1000,UN,25.18,25.18,2.01,25.18,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.66,,,percent of total billed charges,,,,,,,,,25.18,,,percent of total billed charges,,,13.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,13.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,25.18,,,percent of total billed charges,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.68,,,percent of total billed charges,,
D5W KCL 20 MEQ 1000 ML,2500009457,CDM,636,RC,J3480,HCPCS,990790509,NDC,,,,outpatient,facility,1000,UN,25.18,25.18,0.11,618.77,,14.71,,,percent of total billed charges,,,4.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,25.18,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22.66,,,percent of total billed charges,,,,,,,,,25.18,,,percent of total billed charges,,,17.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.13,,,percent of total billed charges,,,25.18,,,percent of total billed charges,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.14,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,5.04,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,25.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.01,,,percent of total billed charges,,,25.18,,,percent of total billed charges,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,25.18,,,percent of total billed charges,,,,,,,,,25.18,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,25.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,25.18,,,percent of total billed charges,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.68,,,percent of total billed charges,,
D5W KCL 20 MEQ 1000 ML,2500009457,CDM,636,RC,J3480,HCPCS,990790509,NDC,999,EAPG,,outpatient,facility,1000,UN,25.18,25.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHL 0.9 KCL 20MEQ 1000ML,2500009458,CDM,636,RC,J3480,HCPCS,264786500,NDC,,,,inpatient,facility,1000,ML,16.57,16.57,1.33,16.57,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.91,,,percent of total billed charges,,,,,,,,,16.57,,,percent of total billed charges,,,9.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,8.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,16.57,,,percent of total billed charges,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.64,,,percent of total billed charges,,
SOD CHL 0.9 KCL 20MEQ 1000ML,2500009458,CDM,636,RC,J3480,HCPCS,264786500,NDC,,,,outpatient,facility,1000,ML,16.57,16.57,0.11,618.77,,9.68,,,percent of total billed charges,,,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.57,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,14.91,,,percent of total billed charges,,,,,,,,,16.57,,,percent of total billed charges,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.64,,,percent of total billed charges,,,16.57,,,percent of total billed charges,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.59,,,percent of total billed charges,,,6.28,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,16.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.33,,,percent of total billed charges,,,16.57,,,percent of total billed charges,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,16.57,,,percent of total billed charges,,,,,,,,,16.57,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.57,,,percent of total billed charges,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.64,,,percent of total billed charges,,
SOD CHL 0.9 KCL 20MEQ 1000ML,2500009458,CDM,636,RC,J3480,HCPCS,264786500,NDC,999,EAPG,,outpatient,facility,1000,ML,16.57,16.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W/0.9  NS KCL 40MEQ 1000ML,2500009459,CDM,636,RC,J3480,HCPCS,338080704,NDC,,,,inpatient,facility,1000,UN,29.77,29.77,2.38,29.77,,,,,,,,,,,,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.79,,,percent of total billed charges,,,,,,,,,29.77,,,percent of total billed charges,,,16.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,29.77,,,percent of total billed charges,,,15.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.9,,,percent of total billed charges,,
D5W/0.9  NS KCL 40MEQ 1000ML,2500009459,CDM,636,RC,J3480,HCPCS,338080704,NDC,,,,outpatient,facility,1000,UN,29.77,29.77,0.11,618.77,,17.39,,,percent of total billed charges,,,5.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,29.77,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26.79,,,percent of total billed charges,,,,,,,,,29.77,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.52,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.63,,,percent of total billed charges,,,11.28,,,percent of total billed charges,,,15.42,,,percent of total billed charges,,,,,,,,,,,,,,,5.95,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,29.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.38,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,29.77,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,,,,,,,29.77,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,29.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,29.77,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.9,,,percent of total billed charges,,
D5W/0.9  NS KCL 40MEQ 1000ML,2500009459,CDM,636,RC,J3480,HCPCS,338080704,NDC,999,EAPG,,outpatient,facility,1000,UN,29.77,29.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W/0.45 NS KCL 20 MEQ 1000ML,2500009461,CDM,636,RC,J3480,HCPCS,990790209,NDC,,,,inpatient,facility,1000,ML,24.45,24.45,1.96,24.45,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22,,,percent of total billed charges,,,,,,,,,24.45,,,percent of total billed charges,,,13.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.17,,,percent of total billed charges,,
D5W/0.45 NS KCL 20 MEQ 1000ML,2500009461,CDM,636,RC,J3480,HCPCS,990790209,NDC,,,,outpatient,facility,1000,ML,24.45,24.45,0.11,618.77,,14.28,,,percent of total billed charges,,,4.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,24.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22,,,percent of total billed charges,,,,,,,,,24.45,,,percent of total billed charges,,,16.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.75,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.58,,,percent of total billed charges,,,9.26,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,24.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.96,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,24.45,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,24.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.17,,,percent of total billed charges,,
D5W/0.45 NS KCL 20 MEQ 1000ML,2500009461,CDM,636,RC,J3480,HCPCS,990790209,NDC,999,EAPG,,outpatient,facility,1000,ML,24.45,24.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W/0.45  NS KCL 40MEQ 1000ML,2500009464,CDM,636,RC,J3480,HCPCS,990790409,NDC,,,,inpatient,facility,1000,UN,24.45,24.45,1.96,24.45,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22,,,percent of total billed charges,,,,,,,,,24.45,,,percent of total billed charges,,,13.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.17,,,percent of total billed charges,,
D5W/0.45  NS KCL 40MEQ 1000ML,2500009464,CDM,636,RC,J3480,HCPCS,990790409,NDC,,,,outpatient,facility,1000,UN,24.45,24.45,0.11,618.77,,14.28,,,percent of total billed charges,,,4.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,24.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22,,,percent of total billed charges,,,,,,,,,24.45,,,percent of total billed charges,,,16.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.75,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.58,,,percent of total billed charges,,,9.26,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,24.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.96,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,24.45,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,24.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.17,,,percent of total billed charges,,
D5W/0.45  NS KCL 40MEQ 1000ML,2500009464,CDM,636,RC,J3480,HCPCS,990790409,NDC,999,EAPG,,outpatient,facility,1000,UN,24.45,24.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W/0.9  NS KCL 20MEQ 1000ML,2500009466,CDM,636,RC,J3480,HCPCS,264765200,NDC,,,,inpatient,facility,1000,UN,16.9,16.9,1.35,16.9,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,,,,16.9,,,percent of total billed charges,,,9.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.87,,,percent of total billed charges,,
D5W/0.9  NS KCL 20MEQ 1000ML,2500009466,CDM,636,RC,J3480,HCPCS,264765200,NDC,,,,outpatient,facility,1000,UN,16.9,16.9,0.11,618.77,,9.87,,,percent of total billed charges,,,3.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.9,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,15.21,,,percent of total billed charges,,,,,,,,,16.9,,,percent of total billed charges,,,11.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.84,,,percent of total billed charges,,,6.4,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,16.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.35,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,,,,,,,16.9,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,16.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.9,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.87,,,percent of total billed charges,,
D5W/0.9  NS KCL 20MEQ 1000ML,2500009466,CDM,636,RC,J3480,HCPCS,264765200,NDC,999,EAPG,,outpatient,facility,1000,UN,16.9,16.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W-LACTATED RINGERS 1000 ML,2500009467,CDM,258,RC,J7121,HCPCS,338012504,NDC,,,,inpatient,facility,1000,UN,10.36,10.36,0.83,10.36,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.32,,,percent of total billed charges,,,,,,,,,10.36,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.27,,,percent of total billed charges,,
D5W-LACTATED RINGERS 1000 ML,2500009467,CDM,258,RC,J7121,HCPCS,338012504,NDC,,,,outpatient,facility,1000,UN,10.36,10.36,0.83,618.77,,6.05,,,percent of total billed charges,,,2.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.36,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.32,,,percent of total billed charges,,,,,,,,,10.36,,,percent of total billed charges,,,7.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.87,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,5.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.07,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,10.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.83,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,,,,,,,10.36,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,7.77,,,percent of total billed charges,,,10.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.36,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.27,,,percent of total billed charges,,
D5W-LACTATED RINGERS 1000 ML,2500009467,CDM,258,RC,J7121,HCPCS,338012504,NDC,999,EAPG,,outpatient,facility,1000,UN,10.36,10.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DAPSONE 25 MG TAB,2500009513,CDM,637,RC,7095413510,NDC,,,,,,inpatient,facility,25,UN,8.15,8.15,0.65,8.15,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.34,,,percent of total billed charges,,,,,,,,,8.15,,,percent of total billed charges,,,4.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,4.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.72,,,percent of total billed charges,,
DAPSONE 25 MG TAB,2500009513,CDM,637,RC,7095413510,NDC,,,,,,outpatient,facility,25,UN,8.15,8.15,0.65,618.77,,4.76,,,percent of total billed charges,,,1.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.15,,,percent of total billed charges,,,7.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.34,,,percent of total billed charges,,,,,,,,,8.15,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,,,,,,,,,,,,,4.4,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.25,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.02,,,percent of total billed charges,,,3.02,,,percent of total billed charges,,,8.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.65,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,8.15,,,fee schedule,,,7.58,,,percent of total billed charges,,,,,,,,,,,,,,,7.58,,,percent of total billed charges,,,7.58,,,percent of total billed charges,,,7.58,,,percent of total billed charges,,,6.11,,,percent of total billed charges,,,8.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.08,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.72,,,percent of total billed charges,,
DAPSONE 25 MG TAB,2500009513,CDM,637,RC,7095413510,NDC,999,EAPG,,,,outpatient,facility,25,UN,8.15,8.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DERMABOND,2500009560,CDM,637,RC,,,,,,,,inpatient,facility,1,UN,87.71,87.71,7.02,87.71,,,,,,,,,,,,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.94,,,percent of total billed charges,,,,,,,,,87.71,,,percent of total billed charges,,,48.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,87.71,,,percent of total billed charges,,,45.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.02,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.59,,,percent of total billed charges,,
DERMABOND,2500009560,CDM,637,RC,,,,,,,,outpatient,facility,1,UN,87.71,87.71,7.02,618.77,,51.22,,,percent of total billed charges,,,17.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,87.71,,,percent of total billed charges,,,77.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,77.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,77.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,32.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,78.94,,,percent of total billed charges,,,,,,,,,87.71,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.36,,,percent of total billed charges,,,,,,,,,,,,,,,47.36,,,percent of total billed charges,,,47.36,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,45.73,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.66,,,percent of total billed charges,,,33.22,,,percent of total billed charges,,,45.43,,,percent of total billed charges,,,,,,,,,,,,,,,17.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,32.45,,,percent of total billed charges,,,32.45,,,percent of total billed charges,,,87.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,87.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.02,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,87.71,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,,,,,,,87.71,,,fee schedule,,,81.59,,,percent of total billed charges,,,,,,,,,,,,,,,81.59,,,percent of total billed charges,,,81.59,,,percent of total billed charges,,,81.59,,,percent of total billed charges,,,65.78,,,percent of total billed charges,,,87.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,87.71,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,61.59,,,percent of total billed charges,,
DERMABOND,2500009560,CDM,637,RC,999,EAPG,,,,,,outpatient,facility,1,UN,87.71,87.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DESIPRAMINE HCL 25 MG TAB,2500009582,CDM,637,RC,2315557901,NDC,,,,,,inpatient,facility,25,UN,6,6,0.48,6,,,,,,,,,,,,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,,,,,,,,6,,,percent of total billed charges,,,3.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,6,,,percent of total billed charges,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,
DESIPRAMINE HCL 25 MG TAB,2500009582,CDM,637,RC,2315557901,NDC,,,,,,outpatient,facility,25,UN,6,6,0.48,618.77,,3.5,,,percent of total billed charges,,,1.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6,,,percent of total billed charges,,,5.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.4,,,percent of total billed charges,,,,,,,,,6,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.61,,,percent of total billed charges,,,,,,,,,,,,,,,3.24,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,6,,,percent of total billed charges,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.56,,,percent of total billed charges,,,2.27,,,percent of total billed charges,,,3.11,,,percent of total billed charges,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.22,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.48,,,percent of total billed charges,,,6,,,percent of total billed charges,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,6,,,percent of total billed charges,,,,,,,,,6,,,fee schedule,,,5.58,,,percent of total billed charges,,,,,,,,,,,,,,,5.58,,,percent of total billed charges,,,5.58,,,percent of total billed charges,,,5.58,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6,,,percent of total billed charges,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.21,,,percent of total billed charges,,
DESIPRAMINE HCL 25 MG TAB,2500009582,CDM,637,RC,2315557901,NDC,999,EAPG,,,,outpatient,facility,25,UN,6,6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DESMOPRESSIN 0.01  NASAL 5 ML,2500009592,CDM,637,RC,4733578891,NDC,,,,,,inpatient,facility,5,UN,812.63,812.63,65.01,812.63,,,,,,,,,,,,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731.37,,,percent of total billed charges,,,,,,,,,812.63,,,percent of total billed charges,,,449.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,741.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,812.63,,,percent of total billed charges,,,423.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.01,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,570.63,,,percent of total billed charges,,
DESMOPRESSIN 0.01  NASAL 5 ML,2500009592,CDM,637,RC,4733578891,NDC,,,,,,outpatient,facility,5,UN,812.63,812.63,65.01,812.63,,474.58,,,percent of total billed charges,,,158.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,812.63,,,percent of total billed charges,,,715.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,715.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,715.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,297.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,731.37,,,percent of total billed charges,,,,,,,,,812.63,,,percent of total billed charges,,,550.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,624.1,,,percent of total billed charges,,,,,,,,,,,,,,,438.82,,,percent of total billed charges,,,438.82,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,423.71,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.6,,,percent of total billed charges,,,307.82,,,percent of total billed charges,,,420.86,,,percent of total billed charges,,,,,,,,,,,,,,,162.53,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,300.67,,,percent of total billed charges,,,300.67,,,percent of total billed charges,,,812.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,812.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,65.01,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,812.63,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,,,,,,,812.63,,,fee schedule,,,755.91,,,percent of total billed charges,,,,,,,,,,,,,,,755.91,,,percent of total billed charges,,,755.91,,,percent of total billed charges,,,755.91,,,percent of total billed charges,,,609.47,,,percent of total billed charges,,,812.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,812.63,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,570.63,,,percent of total billed charges,,
DESMOPRESSIN 0.01  NASAL 5 ML,2500009592,CDM,637,RC,4733578891,NDC,999,EAPG,,,,outpatient,facility,5,UN,812.63,812.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DESMOPRESSIN ACET 0.1 MG TAB,2500009595,CDM,637,RC,2315548901,NDC,,,,,,inpatient,facility,0.1,UN,17.46,17.46,1.4,17.46,,,,,,,,,,,,,,17.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.71,,,percent of total billed charges,,,,,,,,,17.46,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.46,,,percent of total billed charges,,,,,,,,,,,,,,,17.46,,,percent of total billed charges,,,9.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,17.46,,,percent of total billed charges,,,17.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.26,,,percent of total billed charges,,
DESMOPRESSIN ACET 0.1 MG TAB,2500009595,CDM,637,RC,2315548901,NDC,,,,,,outpatient,facility,0.1,UN,17.46,17.46,1.4,618.77,,10.2,,,percent of total billed charges,,,3.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,17.46,,,percent of total billed charges,,,15.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,15.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,15.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,17.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,15.71,,,percent of total billed charges,,,,,,,,,17.46,,,percent of total billed charges,,,11.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.41,,,percent of total billed charges,,,,,,,,,,,,,,,9.43,,,percent of total billed charges,,,9.43,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,17.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.1,,,percent of total billed charges,,,17.46,,,percent of total billed charges,,,17.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,6.61,,,percent of total billed charges,,,9.04,,,percent of total billed charges,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.46,,,percent of total billed charges,,,6.46,,,percent of total billed charges,,,17.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.4,,,percent of total billed charges,,,17.46,,,percent of total billed charges,,,17.46,,,percent of total billed charges,,,,,,,,,,,,,,,17.46,,,percent of total billed charges,,,17.46,,,percent of total billed charges,,,,,,,,,17.46,,,fee schedule,,,16.24,,,percent of total billed charges,,,,,,,,,,,,,,,16.24,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,17.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,17.46,,,percent of total billed charges,,,17.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,12.26,,,percent of total billed charges,,
DESMOPRESSIN ACET 0.1 MG TAB,2500009595,CDM,637,RC,2315548901,NDC,999,EAPG,,,,outpatient,facility,0.1,UN,17.46,17.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXAMETHASONE 0.1  OPH 5 ML,2500009632,CDM,637,RC,2420872002,NDC,,,,,,inpatient,facility,5,UN,177.87,177.87,14.23,177.87,,,,,,,,,,,,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.08,,,percent of total billed charges,,,,,,,,,177.87,,,percent of total billed charges,,,98.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,177.87,,,percent of total billed charges,,,92.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.23,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.9,,,percent of total billed charges,,
DEXAMETHASONE 0.1  OPH 5 ML,2500009632,CDM,637,RC,2420872002,NDC,,,,,,outpatient,facility,5,UN,177.87,177.87,14.23,618.77,,103.88,,,percent of total billed charges,,,34.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,177.87,,,percent of total billed charges,,,156.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,156.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,156.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,65.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,160.08,,,percent of total billed charges,,,,,,,,,177.87,,,percent of total billed charges,,,120.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.6,,,percent of total billed charges,,,,,,,,,,,,,,,96.05,,,percent of total billed charges,,,96.05,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,92.74,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.18,,,percent of total billed charges,,,67.38,,,percent of total billed charges,,,92.12,,,percent of total billed charges,,,,,,,,,,,,,,,35.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,65.81,,,percent of total billed charges,,,65.81,,,percent of total billed charges,,,177.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,177.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.23,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,177.87,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,,,,,,,177.87,,,fee schedule,,,165.45,,,percent of total billed charges,,,,,,,,,,,,,,,165.45,,,percent of total billed charges,,,165.45,,,percent of total billed charges,,,165.45,,,percent of total billed charges,,,133.4,,,percent of total billed charges,,,177.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,177.87,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,124.9,,,percent of total billed charges,,
DEXAMETHASONE 0.1  OPH 5 ML,2500009632,CDM,637,RC,2420872002,NDC,999,EAPG,,,,outpatient,facility,5,UN,177.87,177.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXAMETHASONE 0.5MG/5ML UDC,2500009639,CDM,636,RC,J8540,HCPCS,54317763,NDC,,,,inpatient,facility,5,UN,0.79,0.79,0.06,0.79,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,
DEXAMETHASONE 0.5MG/5ML UDC,2500009639,CDM,636,RC,J8540,HCPCS,54317763,NDC,,,,outpatient,facility,5,UN,0.79,0.79,0.06,618.77,,0.07,,,fee schedule,,,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.71,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,0.79,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.07,,,fee schedule,,,0.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.55,,,percent of total billed charges,,
DEXAMETHASONE 0.5MG/5ML UDC,2500009639,CDM,636,RC,J8540,HCPCS,54317763,NDC,999,EAPG,,outpatient,facility,5,UN,0.79,0.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXAMETHASONE 1 MG TAB,2500009641,CDM,637,RC,J8540,HCPCS,54817425,NDC,,,,inpatient,facility,1,UN,1.22,1.22,0.1,1.22,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,
DEXAMETHASONE 1 MG TAB,2500009641,CDM,637,RC,J8540,HCPCS,54817425,NDC,,,,outpatient,facility,1,UN,1.22,1.22,0.07,618.77,,0.07,,,fee schedule,,,0.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.22,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.1,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,1.22,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.07,,,fee schedule,,,1.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.86,,,percent of total billed charges,,
DEXAMETHASONE 1 MG TAB,2500009641,CDM,637,RC,J8540,HCPCS,54817425,NDC,999,EAPG,,outpatient,facility,1,UN,1.22,1.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXAMETHASONE 4 MG TAB,2500009645,CDM,637,RC,J8540,HCPCS,641614525,NDC,,,,inpatient,facility,1,UN,3.99,3.99,0.32,3.99,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.59,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,
DEXAMETHASONE 4 MG TAB,2500009645,CDM,637,RC,J8540,HCPCS,641614525,NDC,,,,outpatient,facility,1,UN,3.99,3.99,0.07,618.77,,0.07,,,fee schedule,,,0.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.99,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.59,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,3.99,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.07,,,fee schedule,,,3.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.8,,,percent of total billed charges,,
DEXAMETHASONE 4 MG TAB,2500009645,CDM,637,RC,J8540,HCPCS,641614525,NDC,999,EAPG,,outpatient,facility,1,UN,3.99,3.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXMEDETOMIDINE 200MCG/50ML,2500009668,CDM,250,RC,7012113888,NDC,,,,,,inpatient,facility,50,UN,177.21,177.21,14.18,177.21,,,,,,,,,,,,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.49,,,percent of total billed charges,,,,,,,,,177.21,,,percent of total billed charges,,,98.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,177.21,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.18,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.44,,,percent of total billed charges,,
DEXMEDETOMIDINE 200MCG/50ML,2500009668,CDM,250,RC,7012113888,NDC,,,,,,outpatient,facility,50,UN,177.21,177.21,14.18,618.77,,103.49,,,percent of total billed charges,,,34.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,177.21,,,percent of total billed charges,,,156.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,156.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,156.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,64.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,159.49,,,percent of total billed charges,,,,,,,,,177.21,,,percent of total billed charges,,,120.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.68,,,percent of total billed charges,,,67.13,,,percent of total billed charges,,,91.78,,,percent of total billed charges,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,70.88,,,percent of total billed charges,,,70.88,,,percent of total billed charges,,,177.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,177.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.18,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,177.21,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,,,,,,,177.21,,,fee schedule,,,70.88,,,percent of total billed charges,,,,,,,,,,,,,,,70.88,,,percent of total billed charges,,,70.88,,,percent of total billed charges,,,70.88,,,percent of total billed charges,,,132.91,,,percent of total billed charges,,,177.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,177.21,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,124.44,,,percent of total billed charges,,
DEXMEDETOMIDINE 200MCG/50ML,2500009668,CDM,250,RC,7012113888,NDC,999,EAPG,,,,outpatient,facility,50,UN,177.21,177.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXMEDETOMIDINE 400MCG/100ML,2500009669,CDM,250,RC,7012113897,NDC,,,,,,inpatient,facility,100,UN,324.72,324.72,25.98,324.72,,,,,,,,,,,,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,292.25,,,percent of total billed charges,,,,,,,,,324.72,,,percent of total billed charges,,,179.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,324.72,,,percent of total billed charges,,,169.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.98,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.02,,,percent of total billed charges,,
DEXMEDETOMIDINE 400MCG/100ML,2500009669,CDM,250,RC,7012113897,NDC,,,,,,outpatient,facility,100,UN,324.72,324.72,25.98,618.77,,189.64,,,percent of total billed charges,,,63.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,324.72,,,percent of total billed charges,,,285.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,285.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,285.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,118.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,292.25,,,percent of total billed charges,,,,,,,,,324.72,,,percent of total billed charges,,,219.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,169.31,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.79,,,percent of total billed charges,,,123,,,percent of total billed charges,,,168.17,,,percent of total billed charges,,,,,,,,,,,,,,,64.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,129.89,,,percent of total billed charges,,,129.89,,,percent of total billed charges,,,324.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,324.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.98,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,324.72,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,,,,,,,324.72,,,fee schedule,,,129.89,,,percent of total billed charges,,,,,,,,,,,,,,,129.89,,,percent of total billed charges,,,129.89,,,percent of total billed charges,,,129.89,,,percent of total billed charges,,,243.54,,,percent of total billed charges,,,324.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,324.72,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,228.02,,,percent of total billed charges,,
DEXMEDETOMIDINE 400MCG/100ML,2500009669,CDM,250,RC,7012113897,NDC,999,EAPG,,,,outpatient,facility,100,UN,324.72,324.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 10  1000 ML,2500009722,CDM,258,RC,338002304,NDC,,,,,,inpatient,facility,1000,UN,24.92,24.92,1.99,24.92,,,,,,,,,,,,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.43,,,percent of total billed charges,,,,,,,,,24.92,,,percent of total billed charges,,,13.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,24.92,,,percent of total billed charges,,,12.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.5,,,percent of total billed charges,,
DEXTROSE 10  1000 ML,2500009722,CDM,258,RC,338002304,NDC,,,,,,outpatient,facility,1000,UN,24.92,24.92,1.99,618.77,,14.55,,,percent of total billed charges,,,4.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,24.92,,,percent of total billed charges,,,21.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,21.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,21.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22.43,,,percent of total billed charges,,,,,,,,,24.92,,,percent of total billed charges,,,16.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.99,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.94,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,12.91,,,percent of total billed charges,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,9.97,,,percent of total billed charges,,,9.97,,,percent of total billed charges,,,24.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.99,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,24.92,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,,,,,,,24.92,,,fee schedule,,,9.97,,,percent of total billed charges,,,,,,,,,,,,,,,9.97,,,percent of total billed charges,,,9.97,,,percent of total billed charges,,,9.97,,,percent of total billed charges,,,18.69,,,percent of total billed charges,,,24.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,24.92,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.5,,,percent of total billed charges,,
DEXTROSE 10  1000 ML,2500009722,CDM,258,RC,338002304,NDC,999,EAPG,,,,outpatient,facility,1000,UN,24.92,24.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 10  250 ML,2500009723,CDM,258,RC,264752020,NDC,,,,,,inpatient,facility,250,UN,13.27,13.27,1.06,13.27,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.94,,,percent of total billed charges,,,,,,,,,13.27,,,percent of total billed charges,,,7.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,6.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.32,,,percent of total billed charges,,
DEXTROSE 10  250 ML,2500009723,CDM,258,RC,264752020,NDC,,,,,,outpatient,facility,250,UN,13.27,13.27,1.06,618.77,,7.75,,,percent of total billed charges,,,2.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.27,,,percent of total billed charges,,,11.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,11.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,11.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.94,,,percent of total billed charges,,,,,,,,,13.27,,,percent of total billed charges,,,8.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.92,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.09,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,6.87,,,percent of total billed charges,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.31,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,13.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.06,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,13.27,,,fee schedule,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,9.95,,,percent of total billed charges,,,13.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.32,,,percent of total billed charges,,
DEXTROSE 10  250 ML,2500009723,CDM,258,RC,264752020,NDC,999,EAPG,,,,outpatient,facility,250,UN,13.27,13.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 10  500 ML,2500009724,CDM,258,RC,990793002,NDC,,,,,,inpatient,facility,500,UN,36.37,36.37,2.91,36.37,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.73,,,percent of total billed charges,,,,,,,,,36.37,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,18.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,
DEXTROSE 10  500 ML,2500009724,CDM,258,RC,990793002,NDC,,,,,,outpatient,facility,500,UN,36.37,36.37,2.91,618.77,,21.24,,,percent of total billed charges,,,7.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,36.37,,,percent of total billed charges,,,32.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,32.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,32.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,13.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,32.73,,,percent of total billed charges,,,,,,,,,36.37,,,percent of total billed charges,,,24.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.96,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.64,,,percent of total billed charges,,,13.78,,,percent of total billed charges,,,18.84,,,percent of total billed charges,,,,,,,,,,,,,,,7.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,14.55,,,percent of total billed charges,,,14.55,,,percent of total billed charges,,,36.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,36.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.91,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,,,,,,,36.37,,,fee schedule,,,14.55,,,percent of total billed charges,,,,,,,,,,,,,,,14.55,,,percent of total billed charges,,,14.55,,,percent of total billed charges,,,14.55,,,percent of total billed charges,,,27.28,,,percent of total billed charges,,,36.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,36.37,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,25.54,,,percent of total billed charges,,
DEXTROSE 10  500 ML,2500009724,CDM,258,RC,990793002,NDC,999,EAPG,,,,outpatient,facility,500,UN,36.37,36.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 25  10 ML SYR,2500009734,CDM,250,RC,409177510,NDC,,,,,,inpatient,facility,10,UN,56.13,56.13,4.49,56.13,,,,,,,,,,,,,,56.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.52,,,percent of total billed charges,,,,,,,,,56.13,,,percent of total billed charges,,,31.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.13,,,percent of total billed charges,,,,,,,,,,,,,,,56.13,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.49,,,percent of total billed charges,,,56.13,,,percent of total billed charges,,,56.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.41,,,percent of total billed charges,,
DEXTROSE 25  10 ML SYR,2500009734,CDM,250,RC,409177510,NDC,,,,,,outpatient,facility,10,UN,56.13,56.13,4.49,618.77,,32.78,,,percent of total billed charges,,,10.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,56.13,,,percent of total billed charges,,,49.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,49.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,49.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,56.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,20.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,50.52,,,percent of total billed charges,,,,,,,,,56.13,,,percent of total billed charges,,,38.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,56.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.27,,,percent of total billed charges,,,56.13,,,percent of total billed charges,,,56.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.66,,,percent of total billed charges,,,21.26,,,percent of total billed charges,,,29.07,,,percent of total billed charges,,,,,,,,,,,,,,,11.23,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,22.45,,,percent of total billed charges,,,22.45,,,percent of total billed charges,,,56.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,56.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.49,,,percent of total billed charges,,,56.13,,,percent of total billed charges,,,56.13,,,percent of total billed charges,,,,,,,,,,,,,,,56.13,,,percent of total billed charges,,,56.13,,,percent of total billed charges,,,,,,,,,56.13,,,fee schedule,,,22.45,,,percent of total billed charges,,,,,,,,,,,,,,,22.45,,,percent of total billed charges,,,22.45,,,percent of total billed charges,,,22.45,,,percent of total billed charges,,,42.1,,,percent of total billed charges,,,56.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,56.13,,,percent of total billed charges,,,56.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,39.41,,,percent of total billed charges,,
DEXTROSE 25  10 ML SYR,2500009734,CDM,250,RC,409177510,NDC,999,EAPG,,,,outpatient,facility,10,UN,56.13,56.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 5 /0.225  NS 1000ML,2500009753,CDM,258,RC,990792409,NDC,,,,,,inpatient,facility,1000,UN,18.18,18.18,1.45,18.18,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.36,,,percent of total billed charges,,,,,,,,,18.18,,,percent of total billed charges,,,10.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,9.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.77,,,percent of total billed charges,,
DEXTROSE 5 /0.225  NS 1000ML,2500009753,CDM,258,RC,990792409,NDC,,,,,,outpatient,facility,1000,UN,18.18,18.18,1.45,618.77,,10.62,,,percent of total billed charges,,,3.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,18.18,,,percent of total billed charges,,,16.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,16.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,16.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,16.36,,,percent of total billed charges,,,,,,,,,18.18,,,percent of total billed charges,,,12.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.48,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.82,,,percent of total billed charges,,,6.89,,,percent of total billed charges,,,9.42,,,percent of total billed charges,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.27,,,percent of total billed charges,,,7.27,,,percent of total billed charges,,,18.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.45,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,,,,,,,18.18,,,fee schedule,,,7.27,,,percent of total billed charges,,,,,,,,,,,,,,,7.27,,,percent of total billed charges,,,7.27,,,percent of total billed charges,,,7.27,,,percent of total billed charges,,,13.63,,,percent of total billed charges,,,18.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,18.18,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,12.77,,,percent of total billed charges,,
DEXTROSE 5 /0.225  NS 1000ML,2500009753,CDM,258,RC,990792409,NDC,999,EAPG,,,,outpatient,facility,1000,UN,18.18,18.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 5 /0.45  NS 1000 ML,2500009756,CDM,636,RC,S5010,HCPCS,264761200,NDC,,,,inpatient,facility,1000,UN,10.1,10.1,0.81,10.1,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.09,,,percent of total billed charges,,,,,,,,,10.1,,,percent of total billed charges,,,5.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,5.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.09,,,percent of total billed charges,,
DEXTROSE 5 /0.45  NS 1000 ML,2500009756,CDM,636,RC,S5010,HCPCS,264761200,NDC,,,,outpatient,facility,1000,UN,10.1,10.1,0.81,618.77,,5.9,,,percent of total billed charges,,,1.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.1,,,percent of total billed charges,,,10.65,,,fee schedule,,,10.26,,,fee schedule,,,,,,,,,10.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.09,,,percent of total billed charges,,,,,,,,,10.1,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.68,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,5.23,,,percent of total billed charges,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.1,,,fee schedule,,,5.41,,,fee schedule,,,10.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.81,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,,,,,,,10.1,,,fee schedule,,,5.78,,,fee schedule,,,,,,,,,,,,,,,5.08,,,fee schedule,,,6.77,,,fee schedule,,,3.76,,,fee schedule,,,7.57,,,percent of total billed charges,,,10.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.1,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.09,,,percent of total billed charges,,
DEXTROSE 5 /0.45  NS 1000 ML,2500009756,CDM,636,RC,S5010,HCPCS,264761200,NDC,999,EAPG,,outpatient,facility,1000,UN,10.1,10.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 5 /0.45  NS 500 ML,2500009757,CDM,258,RC,264761210,NDC,,,,,,inpatient,facility,500,UN,12.9,12.9,1.03,12.9,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,,,,,,,12.9,,,percent of total billed charges,,,7.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,6.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.06,,,percent of total billed charges,,
DEXTROSE 5 /0.45  NS 500 ML,2500009757,CDM,258,RC,264761210,NDC,,,,,,outpatient,facility,500,UN,12.9,12.9,1.03,618.77,,7.53,,,percent of total billed charges,,,2.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,12.9,,,percent of total billed charges,,,11.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,11.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,11.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.61,,,percent of total billed charges,,,,,,,,,12.9,,,percent of total billed charges,,,8.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.73,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.8,,,percent of total billed charges,,,4.89,,,percent of total billed charges,,,6.68,,,percent of total billed charges,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.16,,,percent of total billed charges,,,5.16,,,percent of total billed charges,,,12.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.03,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,,,,,,,12.9,,,fee schedule,,,5.16,,,percent of total billed charges,,,,,,,,,,,,,,,5.16,,,percent of total billed charges,,,5.16,,,percent of total billed charges,,,5.16,,,percent of total billed charges,,,9.68,,,percent of total billed charges,,,12.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,12.9,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.06,,,percent of total billed charges,,
DEXTROSE 5 /0.45  NS 500 ML,2500009757,CDM,258,RC,264761210,NDC,999,EAPG,,,,outpatient,facility,500,UN,12.9,12.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 50  50 ML INJ,2500009760,CDM,250,RC,J3490,HCPCS,409751716,NDC,,,,inpatient,facility,50,UN,53.79,53.79,4.3,53.79,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.41,,,percent of total billed charges,,,,,,,,,53.79,,,percent of total billed charges,,,29.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.77,,,percent of total billed charges,,
DEXTROSE 50  50 ML INJ,2500009760,CDM,250,RC,J3490,HCPCS,409751716,NDC,,,,outpatient,facility,50,UN,53.79,53.79,1.2,618.77,,31.41,,,percent of total billed charges,,,10.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,53.79,,,percent of total billed charges,,,47.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,47.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,47.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,19.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,48.41,,,percent of total billed charges,,,,,,,,,53.79,,,percent of total billed charges,,,36.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.31,,,percent of total billed charges,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.88,,,percent of total billed charges,,,20.38,,,percent of total billed charges,,,27.86,,,percent of total billed charges,,,,,,,,,,,,,,,10.76,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,53.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.3,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,,,,,,,53.79,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,40.34,,,percent of total billed charges,,,53.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,53.79,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,37.77,,,percent of total billed charges,,
DEXTROSE 50  50 ML INJ,2500009760,CDM,250,RC,J3490,HCPCS,409751716,NDC,435,EAPG,,outpatient,facility,50,UN,53.79,53.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 50  50 ML INJ,2500009761,CDM,250,RC,409664802,NDC,,,,,,inpatient,facility,50,UN,12.64,12.64,1.01,12.64,,,,,,,,,,,,,,12.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.38,,,percent of total billed charges,,,,,,,,,12.64,,,percent of total billed charges,,,7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.64,,,percent of total billed charges,,,,,,,,,,,,,,,12.64,,,percent of total billed charges,,,6.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,12.64,,,percent of total billed charges,,,12.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.88,,,percent of total billed charges,,
DEXTROSE 50  50 ML INJ,2500009761,CDM,250,RC,409664802,NDC,,,,,,outpatient,facility,50,UN,12.64,12.64,1.01,618.77,,7.38,,,percent of total billed charges,,,2.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,12.64,,,percent of total billed charges,,,11.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,11.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,11.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.38,,,percent of total billed charges,,,,,,,,,12.64,,,percent of total billed charges,,,8.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,12.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.59,,,percent of total billed charges,,,12.64,,,percent of total billed charges,,,12.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.61,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,6.55,,,percent of total billed charges,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.06,,,percent of total billed charges,,,5.06,,,percent of total billed charges,,,12.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.01,,,percent of total billed charges,,,12.64,,,percent of total billed charges,,,12.64,,,percent of total billed charges,,,,,,,,,,,,,,,12.64,,,percent of total billed charges,,,12.64,,,percent of total billed charges,,,,,,,,,12.64,,,fee schedule,,,5.06,,,percent of total billed charges,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,,5.06,,,percent of total billed charges,,,5.06,,,percent of total billed charges,,,9.48,,,percent of total billed charges,,,12.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,12.64,,,percent of total billed charges,,,12.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.88,,,percent of total billed charges,,
DEXTROSE 50  50 ML INJ,2500009761,CDM,250,RC,409664802,NDC,999,EAPG,,,,outpatient,facility,50,UN,12.64,12.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIAZEPAM 2 MG TAB,2500009822,CDM,637,RC,172392560,NDC,,,,,,inpatient,facility,2,UN,0.43,0.43,0.03,0.43,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,
DIAZEPAM 2 MG TAB,2500009822,CDM,637,RC,172392560,NDC,,,,,,outpatient,facility,2,UN,0.43,0.43,0.03,618.77,,0.25,,,percent of total billed charges,,,0.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.43,,,percent of total billed charges,,,0.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.39,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.16,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,0.43,,,fee schedule,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,0.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.3,,,percent of total billed charges,,
DIAZEPAM 2 MG TAB,2500009822,CDM,637,RC,172392560,NDC,999,EAPG,,,,outpatient,facility,2,UN,0.43,0.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIAZEPAM 5 MG TAB,2500009823,CDM,637,RC,6809475062,NDC,,,,,,inpatient,facility,5,UN,1.05,1.05,0.08,1.05,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,1.05,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,
DIAZEPAM 5 MG TAB,2500009823,CDM,637,RC,6809475062,NDC,,,,,,outpatient,facility,5,UN,1.05,1.05,0.08,618.77,,0.61,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.05,,,percent of total billed charges,,,0.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.95,,,percent of total billed charges,,,,,,,,,1.05,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,1.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,1.05,,,fee schedule,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,1.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.74,,,percent of total billed charges,,
DIAZEPAM 5 MG TAB,2500009823,CDM,637,RC,6809475062,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.05,1.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIAZEPAM RECTAL 2.5 MG/KIT,2500009827,CDM,637,RC,6868265020,NDC,,,,,,inpatient,facility,2.5,UN,422,422,33.76,422,,,,,,,,,,,,,,422,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,379.8,,,percent of total billed charges,,,,,,,,,422,,,percent of total billed charges,,,233.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422,,,percent of total billed charges,,,,,,,,,,,,,,,422,,,percent of total billed charges,,,220.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.76,,,percent of total billed charges,,,422,,,percent of total billed charges,,,422,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,422,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.33,,,percent of total billed charges,,
DIAZEPAM RECTAL 2.5 MG/KIT,2500009827,CDM,637,RC,6868265020,NDC,,,,,,outpatient,facility,2.5,UN,422,422,33.76,618.77,,246.45,,,percent of total billed charges,,,82.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,422,,,percent of total billed charges,,,371.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,371.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,371.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,422,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,154.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,379.8,,,percent of total billed charges,,,,,,,,,422,,,percent of total billed charges,,,285.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,324.1,,,percent of total billed charges,,,,,,,,,,,,,,,227.88,,,percent of total billed charges,,,227.88,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,422,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,220.03,,,percent of total billed charges,,,422,,,percent of total billed charges,,,422,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.72,,,percent of total billed charges,,,159.85,,,percent of total billed charges,,,218.55,,,percent of total billed charges,,,,,,,,,,,,,,,84.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,156.14,,,percent of total billed charges,,,156.14,,,percent of total billed charges,,,422,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,422,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33.76,,,percent of total billed charges,,,422,,,percent of total billed charges,,,422,,,percent of total billed charges,,,,,,,,,,,,,,,422,,,percent of total billed charges,,,422,,,percent of total billed charges,,,,,,,,,422,,,fee schedule,,,392.54,,,percent of total billed charges,,,,,,,,,,,,,,,392.54,,,percent of total billed charges,,,392.54,,,percent of total billed charges,,,392.54,,,percent of total billed charges,,,316.5,,,percent of total billed charges,,,422,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,422,,,percent of total billed charges,,,422,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,296.33,,,percent of total billed charges,,
DIAZEPAM RECTAL 2.5 MG/KIT,2500009827,CDM,637,RC,6868265020,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,422,422,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIAZOXIDE SUSP 50 MG/ML,2500009830,CDM,637,RC,254101019,NDC,,,,,,inpatient,facility,1,UN,40.92,40.92,3.27,40.92,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.83,,,percent of total billed charges,,,,,,,,,40.92,,,percent of total billed charges,,,22.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,21.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.27,,,percent of total billed charges,,,40.92,,,percent of total billed charges,,,40.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.73,,,percent of total billed charges,,
DIAZOXIDE SUSP 50 MG/ML,2500009830,CDM,637,RC,254101019,NDC,,,,,,outpatient,facility,1,UN,40.92,40.92,3.27,618.77,,23.9,,,percent of total billed charges,,,7.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,40.92,,,percent of total billed charges,,,36.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,36.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,36.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,14.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,36.83,,,percent of total billed charges,,,,,,,,,40.92,,,percent of total billed charges,,,27.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.43,,,percent of total billed charges,,,,,,,,,,,,,,,22.1,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,40.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.34,,,percent of total billed charges,,,40.92,,,percent of total billed charges,,,40.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.1,,,percent of total billed charges,,,15.5,,,percent of total billed charges,,,21.19,,,percent of total billed charges,,,,,,,,,,,,,,,8.18,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,15.14,,,percent of total billed charges,,,15.14,,,percent of total billed charges,,,40.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.27,,,percent of total billed charges,,,40.92,,,percent of total billed charges,,,40.92,,,percent of total billed charges,,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,40.92,,,percent of total billed charges,,,,,,,,,40.92,,,fee schedule,,,38.06,,,percent of total billed charges,,,,,,,,,,,,,,,38.06,,,percent of total billed charges,,,38.06,,,percent of total billed charges,,,38.06,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,40.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,40.92,,,percent of total billed charges,,,40.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,28.73,,,percent of total billed charges,,
DIAZOXIDE SUSP 50 MG/ML,2500009830,CDM,637,RC,254101019,NDC,999,EAPG,,,,outpatient,facility,1,UN,40.92,40.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DICLOFENAC 1  GEL 100 GM,2500009861,CDM,637,RC,6909752444,NDC,,,,,,inpatient,facility,100,UN,173.65,173.65,13.89,173.65,,,,,,,,,,,,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,percent of total billed charges,,,,,,,,,173.65,,,percent of total billed charges,,,96.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,173.65,,,percent of total billed charges,,,90.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.89,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.94,,,percent of total billed charges,,
DICLOFENAC 1  GEL 100 GM,2500009861,CDM,637,RC,6909752444,NDC,,,,,,outpatient,facility,100,UN,173.65,173.65,13.89,618.77,,101.41,,,percent of total billed charges,,,33.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,173.65,,,percent of total billed charges,,,152.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,152.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,152.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,63.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,156.28,,,percent of total billed charges,,,,,,,,,173.65,,,percent of total billed charges,,,117.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.36,,,percent of total billed charges,,,,,,,,,,,,,,,93.77,,,percent of total billed charges,,,93.77,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.54,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.97,,,percent of total billed charges,,,65.78,,,percent of total billed charges,,,89.93,,,percent of total billed charges,,,,,,,,,,,,,,,34.73,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,64.25,,,percent of total billed charges,,,64.25,,,percent of total billed charges,,,173.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,173.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.89,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,173.65,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,,,,,,,173.65,,,fee schedule,,,161.53,,,percent of total billed charges,,,,,,,,,,,,,,,161.53,,,percent of total billed charges,,,161.53,,,percent of total billed charges,,,161.53,,,percent of total billed charges,,,130.24,,,percent of total billed charges,,,173.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,173.65,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,121.94,,,percent of total billed charges,,
DICLOFENAC 1  GEL 100 GM,2500009861,CDM,637,RC,6909752444,NDC,999,EAPG,,,,outpatient,facility,100,UN,173.65,173.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DICLOFENAC SOD 25 MG TABEC,2500009863,CDM,637,RC,1657120310,NDC,,,,,,inpatient,facility,25,UN,4.68,4.68,0.37,4.68,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.29,,,percent of total billed charges,,
DICLOFENAC SOD 25 MG TABEC,2500009863,CDM,637,RC,1657120310,NDC,,,,,,outpatient,facility,25,UN,4.68,4.68,0.37,618.77,,2.73,,,percent of total billed charges,,,0.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.68,,,percent of total billed charges,,,4.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.21,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.59,,,percent of total billed charges,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,2.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.44,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.73,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,4.68,,,fee schedule,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,4.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.29,,,percent of total billed charges,,
DICLOFENAC SOD 25 MG TABEC,2500009863,CDM,637,RC,1657120310,NDC,999,EAPG,,,,outpatient,facility,25,UN,4.68,4.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DICYCLOMINE HCL 10 MG CAP,2500009880,CDM,637,RC,904698761,NDC,,,,,,inpatient,facility,10,UN,1.88,1.88,0.15,1.88,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,
DICYCLOMINE HCL 10 MG CAP,2500009880,CDM,637,RC,904698761,NDC,,,,,,outpatient,facility,10,UN,1.88,1.88,0.15,618.77,,1.1,,,percent of total billed charges,,,0.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.88,,,percent of total billed charges,,,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.69,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.7,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,1.88,,,fee schedule,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.32,,,percent of total billed charges,,
DICYCLOMINE HCL 10 MG CAP,2500009880,CDM,637,RC,904698761,NDC,999,EAPG,,,,outpatient,facility,10,UN,1.88,1.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DICYCLOMINE HCL 20 MG TAB,2500009882,CDM,637,RC,904698861,NDC,,,,,,inpatient,facility,20,UN,1.85,1.85,0.15,1.85,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,
DICYCLOMINE HCL 20 MG TAB,2500009882,CDM,637,RC,904698861,NDC,,,,,,outpatient,facility,20,UN,1.85,1.85,0.15,618.77,,1.08,,,percent of total billed charges,,,0.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.85,,,percent of total billed charges,,,1.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.67,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,1.85,,,fee schedule,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,1.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.3,,,percent of total billed charges,,
DICYCLOMINE HCL 20 MG TAB,2500009882,CDM,637,RC,904698861,NDC,999,EAPG,,,,outpatient,facility,20,UN,1.85,1.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIGOXIN 0.125 MG TAB,2500009940,CDM,637,RC,904592161,NDC,,,,,,inpatient,facility,0.125,UN,4.46,4.46,0.36,4.46,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,,,,,,,4.46,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,
DIGOXIN 0.125 MG TAB,2500009940,CDM,637,RC,904592161,NDC,,,,,,outpatient,facility,0.125,UN,4.46,4.46,0.36,618.77,,2.6,,,percent of total billed charges,,,0.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.46,,,percent of total billed charges,,,3.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.01,,,percent of total billed charges,,,,,,,,,4.46,,,percent of total billed charges,,,3.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,1.69,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,4.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.36,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,4.46,,,fee schedule,,,4.15,,,percent of total billed charges,,,,,,,,,,,,,,,4.15,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,3.34,,,percent of total billed charges,,,4.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.13,,,percent of total billed charges,,
DIGOXIN 0.125 MG TAB,2500009940,CDM,637,RC,904592161,NDC,999,EAPG,,,,outpatient,facility,0.125,UN,4.46,4.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIGOXIN 0.25 MG TAB,2500009941,CDM,637,RC,904592261,NDC,,,,,,inpatient,facility,0.25,UN,4.46,4.46,0.36,4.46,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,,,,,,,4.46,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,
DIGOXIN 0.25 MG TAB,2500009941,CDM,637,RC,904592261,NDC,,,,,,outpatient,facility,0.25,UN,4.46,4.46,0.36,618.77,,2.6,,,percent of total billed charges,,,0.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.46,,,percent of total billed charges,,,3.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.01,,,percent of total billed charges,,,,,,,,,4.46,,,percent of total billed charges,,,3.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,1.69,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,4.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.36,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,4.46,,,fee schedule,,,4.15,,,percent of total billed charges,,,,,,,,,,,,,,,4.15,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,3.34,,,percent of total billed charges,,,4.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.13,,,percent of total billed charges,,
DIGOXIN 0.25 MG TAB,2500009941,CDM,637,RC,904592261,NDC,999,EAPG,,,,outpatient,facility,0.25,UN,4.46,4.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM CD 120 MG CAPCR,2500009970,CDM,637,RC,6050500146,NDC,,,,,,inpatient,facility,120,UN,3.76,3.76,0.3,3.76,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,
DILTIAZEM CD 120 MG CAPCR,2500009970,CDM,637,RC,6050500146,NDC,,,,,,outpatient,facility,120,UN,3.76,3.76,0.3,618.77,,2.2,,,percent of total billed charges,,,0.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.76,,,percent of total billed charges,,,3.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.38,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,3.76,,,fee schedule,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,2.82,,,percent of total billed charges,,,3.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.64,,,percent of total billed charges,,
DILTIAZEM CD 120 MG CAPCR,2500009970,CDM,637,RC,6050500146,NDC,999,EAPG,,,,outpatient,facility,120,UN,3.76,3.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM CD 180 MG CAPCR,2500009972,CDM,637,RC,6050500156,NDC,,,,,,inpatient,facility,180,UN,4.42,4.42,0.35,4.42,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.98,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,
DILTIAZEM CD 180 MG CAPCR,2500009972,CDM,637,RC,6050500156,NDC,,,,,,outpatient,facility,180,UN,4.42,4.42,0.35,618.77,,2.58,,,percent of total billed charges,,,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.42,,,percent of total billed charges,,,3.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.98,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.64,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,4.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.35,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,4.42,,,fee schedule,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,4.11,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,4.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.1,,,percent of total billed charges,,
DILTIAZEM CD 180 MG CAPCR,2500009972,CDM,637,RC,6050500156,NDC,999,EAPG,,,,outpatient,facility,180,UN,4.42,4.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM CD 240 MG CAPCR,2500009974,CDM,637,RC,6050500166,NDC,,,,,,inpatient,facility,240,UN,4.72,4.72,0.38,4.72,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.25,,,percent of total billed charges,,,,,,,,,4.72,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,
DILTIAZEM CD 240 MG CAPCR,2500009974,CDM,637,RC,6050500166,NDC,,,,,,outpatient,facility,240,UN,4.72,4.72,0.38,618.77,,2.76,,,percent of total billed charges,,,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.72,,,percent of total billed charges,,,4.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.25,,,percent of total billed charges,,,,,,,,,4.72,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.62,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.59,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,4.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.38,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,4.72,,,fee schedule,,,4.39,,,percent of total billed charges,,,,,,,,,,,,,,,4.39,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,4.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.31,,,percent of total billed charges,,
DILTIAZEM CD 240 MG CAPCR,2500009974,CDM,637,RC,6050500166,NDC,999,EAPG,,,,outpatient,facility,240,UN,4.72,4.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM HCL 25 MG/5 ML INJ,2500009982,CDM,250,RC,J3490,HCPCS,7086030105,NDC,,,,inpatient,facility,5,UN,10.73,10.73,0.86,10.73,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.66,,,percent of total billed charges,,,,,,,,,10.73,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,5.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.53,,,percent of total billed charges,,
DILTIAZEM HCL 25 MG/5 ML INJ,2500009982,CDM,250,RC,J3490,HCPCS,7086030105,NDC,,,,outpatient,facility,5,UN,10.73,10.73,0.86,618.77,,6.27,,,percent of total billed charges,,,2.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.73,,,percent of total billed charges,,,9.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,9.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,9.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.66,,,percent of total billed charges,,,,,,,,,10.73,,,percent of total billed charges,,,7.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.24,,,percent of total billed charges,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.59,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,5.56,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,10.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.86,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,,,,,,,10.73,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,8.05,,,percent of total billed charges,,,10.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.73,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.37,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.53,,,percent of total billed charges,,
DILTIAZEM HCL 25 MG/5 ML INJ,2500009982,CDM,250,RC,J3490,HCPCS,7086030105,NDC,435,EAPG,,outpatient,facility,5,UN,10.73,10.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM HCL 30 MG TAB,2500009983,CDM,637,RC,93031801,NDC,,,,,,inpatient,facility,30,UN,3.3,3.3,0.26,3.3,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,3.3,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,
DILTIAZEM HCL 30 MG TAB,2500009983,CDM,637,RC,93031801,NDC,,,,,,outpatient,facility,30,UN,3.3,3.3,0.26,618.77,,1.93,,,percent of total billed charges,,,0.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.3,,,percent of total billed charges,,,2.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.97,,,percent of total billed charges,,,,,,,,,3.3,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,3.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,3.3,,,fee schedule,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,3.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.32,,,percent of total billed charges,,
DILTIAZEM HCL 30 MG TAB,2500009983,CDM,637,RC,93031801,NDC,999,EAPG,,,,outpatient,facility,30,UN,3.3,3.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM HCL 125 MG/25ML INJ,2500009986,CDM,250,RC,J3490,HCPCS,7086030125,NDC,,,,inpatient,facility,25,UN,32.18,32.18,2.57,32.18,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.96,,,percent of total billed charges,,,,,,,,,32.18,,,percent of total billed charges,,,17.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,16.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.6,,,percent of total billed charges,,
DILTIAZEM HCL 125 MG/25ML INJ,2500009986,CDM,250,RC,J3490,HCPCS,7086030125,NDC,,,,outpatient,facility,25,UN,32.18,32.18,1.2,618.77,,18.79,,,percent of total billed charges,,,6.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,32.18,,,percent of total billed charges,,,28.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,28.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,28.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,28.96,,,percent of total billed charges,,,,,,,,,32.18,,,percent of total billed charges,,,21.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.71,,,percent of total billed charges,,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.78,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.46,,,percent of total billed charges,,,12.19,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,6.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,32.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.57,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,,,,,,,32.18,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,24.13,,,percent of total billed charges,,,32.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,32.18,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,22.6,,,percent of total billed charges,,
DILTIAZEM HCL 125 MG/25ML INJ,2500009986,CDM,250,RC,J3490,HCPCS,7086030125,NDC,435,EAPG,,outpatient,facility,25,UN,32.18,32.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM HCL 60 MG TAB,2500009988,CDM,637,RC,93031901,NDC,,,,,,inpatient,facility,60,UN,5.18,5.18,0.41,5.18,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.66,,,percent of total billed charges,,,,,,,,,5.18,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,
DILTIAZEM HCL 60 MG TAB,2500009988,CDM,637,RC,93031901,NDC,,,,,,outpatient,facility,60,UN,5.18,5.18,0.41,618.77,,3.03,,,percent of total billed charges,,,1.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.18,,,percent of total billed charges,,,4.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.66,,,percent of total billed charges,,,,,,,,,5.18,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.94,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,5.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.41,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,,,,,,,5.18,,,fee schedule,,,4.82,,,percent of total billed charges,,,,,,,,,,,,,,,4.82,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,3.88,,,percent of total billed charges,,,5.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.18,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.64,,,percent of total billed charges,,
DILTIAZEM HCL 60 MG TAB,2500009988,CDM,637,RC,93031901,NDC,999,EAPG,,,,outpatient,facility,60,UN,5.18,5.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM SR 60 MG CAPCR,2500009990,CDM,637,RC,5107992420,NDC,,,,,,inpatient,facility,60,UN,13.1,13.1,1.05,13.1,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.79,,,percent of total billed charges,,,,,,,,,13.1,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.2,,,percent of total billed charges,,
DILTIAZEM SR 60 MG CAPCR,2500009990,CDM,637,RC,5107992420,NDC,,,,,,outpatient,facility,60,UN,13.1,13.1,1.05,618.77,,7.65,,,percent of total billed charges,,,2.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.1,,,percent of total billed charges,,,11.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,11.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,11.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.79,,,percent of total billed charges,,,,,,,,,13.1,,,percent of total billed charges,,,8.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.06,,,percent of total billed charges,,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,,7.07,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.96,,,percent of total billed charges,,,4.96,,,percent of total billed charges,,,6.78,,,percent of total billed charges,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.85,,,percent of total billed charges,,,4.85,,,percent of total billed charges,,,13.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.05,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,,,,,,,13.1,,,fee schedule,,,12.19,,,percent of total billed charges,,,,,,,,,,,,,,,12.19,,,percent of total billed charges,,,12.19,,,percent of total billed charges,,,12.19,,,percent of total billed charges,,,9.82,,,percent of total billed charges,,,13.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.1,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.2,,,percent of total billed charges,,
DILTIAZEM SR 60 MG CAPCR,2500009990,CDM,637,RC,5107992420,NDC,999,EAPG,,,,outpatient,facility,60,UN,13.1,13.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIPHENHYDRAMINE 25 MG CAP,2500010051,CDM,637,RC,904530661,NDC,,,,,,inpatient,facility,25,UN,1.5,1.5,0.12,1.5,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,1.5,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,
DIPHENHYDRAMINE 25 MG CAP,2500010051,CDM,637,RC,904530661,NDC,,,,,,outpatient,facility,25,UN,1.5,1.5,0.12,618.77,,0.88,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.5,,,percent of total billed charges,,,1.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.35,,,percent of total billed charges,,,,,,,,,1.5,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,1.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,1.5,,,fee schedule,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.05,,,percent of total billed charges,,
DIPHENHYDRAMINE 25 MG CAP,2500010051,CDM,637,RC,904530661,NDC,999,EAPG,,,,outpatient,facility,25,UN,1.5,1.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIPHENHYDRAMINE 25 MG/10 ML UD,2500010057,CDM,637,RC,121097800,NDC,,,,,,inpatient,facility,10,UN,14.88,14.88,1.19,14.88,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.39,,,percent of total billed charges,,,,,,,,,14.88,,,percent of total billed charges,,,8.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,7.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.45,,,percent of total billed charges,,
DIPHENHYDRAMINE 25 MG/10 ML UD,2500010057,CDM,637,RC,121097800,NDC,,,,,,outpatient,facility,10,UN,14.88,14.88,1.19,618.77,,8.69,,,percent of total billed charges,,,2.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.88,,,percent of total billed charges,,,13.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,13.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,13.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.39,,,percent of total billed charges,,,,,,,,,14.88,,,percent of total billed charges,,,10.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.43,,,percent of total billed charges,,,,,,,,,,,,,,,8.04,,,percent of total billed charges,,,8.04,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.76,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,7.71,,,percent of total billed charges,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,14.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.19,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,,,,,,,14.88,,,fee schedule,,,13.84,,,percent of total billed charges,,,,,,,,,,,,,,,13.84,,,percent of total billed charges,,,13.84,,,percent of total billed charges,,,13.84,,,percent of total billed charges,,,11.16,,,percent of total billed charges,,,14.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.88,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.45,,,percent of total billed charges,,
DIPHENHYDRAMINE 25 MG/10 ML UD,2500010057,CDM,637,RC,121097800,NDC,999,EAPG,,,,outpatient,facility,10,UN,14.88,14.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIPHENOXYLATE/ATR 2.5 MG TAB,2500010070,CDM,637,RC,5976210611,NDC,,,,,,inpatient,facility,1,UN,1.35,1.35,0.11,1.35,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,
DIPHENOXYLATE/ATR 2.5 MG TAB,2500010070,CDM,637,RC,5976210611,NDC,,,,,,outpatient,facility,1,UN,1.35,1.35,0.11,618.77,,0.79,,,percent of total billed charges,,,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.35,,,percent of total billed charges,,,1.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.22,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,1.35,,,fee schedule,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.95,,,percent of total billed charges,,
DIPHENOXYLATE/ATR 2.5 MG TAB,2500010070,CDM,637,RC,5976210611,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.35,1.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIPYRIDAMOLE/ASA CR 200-25 MG,2500010095,CDM,637,RC,6846240560,NDC,,,,,,inpatient,facility,1,UN,27.59,27.59,2.21,27.59,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.83,,,percent of total billed charges,,,,,,,,,27.59,,,percent of total billed charges,,,15.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,14.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.37,,,percent of total billed charges,,
DIPYRIDAMOLE/ASA CR 200-25 MG,2500010095,CDM,637,RC,6846240560,NDC,,,,,,outpatient,facility,1,UN,27.59,27.59,2.21,618.77,,16.11,,,percent of total billed charges,,,5.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,27.59,,,percent of total billed charges,,,24.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,24.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,24.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,24.83,,,percent of total billed charges,,,,,,,,,27.59,,,percent of total billed charges,,,18.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.19,,,percent of total billed charges,,,,,,,,,,,,,,,14.9,,,percent of total billed charges,,,14.9,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.39,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.97,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,14.29,,,percent of total billed charges,,,,,,,,,,,,,,,5.52,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.21,,,percent of total billed charges,,,10.21,,,percent of total billed charges,,,27.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.21,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,,,,,,,27.59,,,fee schedule,,,25.66,,,percent of total billed charges,,,,,,,,,,,,,,,25.66,,,percent of total billed charges,,,25.66,,,percent of total billed charges,,,25.66,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,27.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,27.59,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.79,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,19.37,,,percent of total billed charges,,
DIPYRIDAMOLE/ASA CR 200-25 MG,2500010095,CDM,637,RC,6846240560,NDC,999,EAPG,,,,outpatient,facility,1,UN,27.59,27.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISOPYRAMIDE 100 MG CAP,2500010100,CDM,637,RC,93312701,NDC,,,,,,inpatient,facility,100,UN,9.44,9.44,0.76,9.44,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.5,,,percent of total billed charges,,,,,,,,,9.44,,,percent of total billed charges,,,5.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,
DISOPYRAMIDE 100 MG CAP,2500010100,CDM,637,RC,93312701,NDC,,,,,,outpatient,facility,100,UN,9.44,9.44,0.76,618.77,,5.51,,,percent of total billed charges,,,1.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.44,,,percent of total billed charges,,,8.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,8.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,8.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.5,,,percent of total billed charges,,,,,,,,,9.44,,,percent of total billed charges,,,6.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,5.1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.17,,,percent of total billed charges,,,3.58,,,percent of total billed charges,,,4.89,,,percent of total billed charges,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.49,,,percent of total billed charges,,,3.49,,,percent of total billed charges,,,9.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.76,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,9.44,,,fee schedule,,,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,7.08,,,percent of total billed charges,,,9.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.44,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.63,,,percent of total billed charges,,
DISOPYRAMIDE 100 MG CAP,2500010100,CDM,637,RC,93312701,NDC,999,EAPG,,,,outpatient,facility,100,UN,9.44,9.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISULFIRAM 250 MG TAB,2500010110,CDM,637,RC,4778160730,NDC,,,,,,inpatient,facility,250,UN,13.33,13.33,1.07,13.33,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12,,,percent of total billed charges,,,,,,,,,13.33,,,percent of total billed charges,,,7.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,6.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.36,,,percent of total billed charges,,
DISULFIRAM 250 MG TAB,2500010110,CDM,637,RC,4778160730,NDC,,,,,,outpatient,facility,250,UN,13.33,13.33,1.07,618.77,,7.78,,,percent of total billed charges,,,2.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.33,,,percent of total billed charges,,,11.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,11.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,11.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12,,,percent of total billed charges,,,,,,,,,13.33,,,percent of total billed charges,,,9.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.24,,,percent of total billed charges,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,7.2,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.95,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.13,,,percent of total billed charges,,,5.05,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.93,,,percent of total billed charges,,,4.93,,,percent of total billed charges,,,13.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.07,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,,,,,,,13.33,,,fee schedule,,,12.4,,,percent of total billed charges,,,,,,,,,,,,,,,12.4,,,percent of total billed charges,,,12.4,,,percent of total billed charges,,,12.4,,,percent of total billed charges,,,10,,,percent of total billed charges,,,13.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.33,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.67,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.36,,,percent of total billed charges,,
DISULFIRAM 250 MG TAB,2500010110,CDM,637,RC,4778160730,NDC,999,EAPG,,,,outpatient,facility,250,UN,13.33,13.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIVALPROEX  SOD 125 MG TAB-EC,2500010121,CDM,637,RC,6068721121,NDC,,,,,,inpatient,facility,125,UN,2.94,2.94,0.24,2.94,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,,,,,,,2.94,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,
DIVALPROEX  SOD 125 MG TAB-EC,2500010121,CDM,637,RC,6068721121,NDC,,,,,,outpatient,facility,125,UN,2.94,2.94,0.24,618.77,,1.72,,,percent of total billed charges,,,0.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.94,,,percent of total billed charges,,,2.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.65,,,percent of total billed charges,,,,,,,,,2.94,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,2.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,2.94,,,fee schedule,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.94,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.06,,,percent of total billed charges,,
DIVALPROEX  SOD 125 MG TAB-EC,2500010121,CDM,637,RC,6068721121,NDC,999,EAPG,,,,outpatient,facility,125,UN,2.94,2.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIVALPROEX  SOD 250 MG TABEC,2500010122,CDM,637,RC,904686061,NDC,,,,,,inpatient,facility,250,UN,0.66,0.66,0.05,0.66,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,
DIVALPROEX  SOD 250 MG TABEC,2500010122,CDM,637,RC,904686061,NDC,,,,,,outpatient,facility,250,UN,0.66,0.66,0.05,618.77,,0.39,,,percent of total billed charges,,,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.66,,,percent of total billed charges,,,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.59,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,0.66,,,fee schedule,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.46,,,percent of total billed charges,,
DIVALPROEX  SOD 250 MG TABEC,2500010122,CDM,637,RC,904686061,NDC,999,EAPG,,,,outpatient,facility,250,UN,0.66,0.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIVALPROEX  SOD 500 MG TABEC,2500010125,CDM,637,RC,832712401,NDC,,,,,,inpatient,facility,500,UN,4.69,4.69,0.38,4.69,,,,,,,,,,,,,,4.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,4.69,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.69,,,percent of total billed charges,,,,,,,,,,,,,,,4.69,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,4.69,,,percent of total billed charges,,,4.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.29,,,percent of total billed charges,,
DIVALPROEX  SOD 500 MG TABEC,2500010125,CDM,637,RC,832712401,NDC,,,,,,outpatient,facility,500,UN,4.69,4.69,0.38,618.77,,2.74,,,percent of total billed charges,,,0.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.69,,,percent of total billed charges,,,4.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.22,,,percent of total billed charges,,,,,,,,,4.69,,,percent of total billed charges,,,3.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.6,,,percent of total billed charges,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,2.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,4.69,,,percent of total billed charges,,,4.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.74,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,4.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.38,,,percent of total billed charges,,,4.69,,,percent of total billed charges,,,4.69,,,percent of total billed charges,,,,,,,,,,,,,,,4.69,,,percent of total billed charges,,,4.69,,,percent of total billed charges,,,,,,,,,4.69,,,fee schedule,,,4.36,,,percent of total billed charges,,,,,,,,,,,,,,,4.36,,,percent of total billed charges,,,4.36,,,percent of total billed charges,,,4.36,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,4.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.69,,,percent of total billed charges,,,4.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.29,,,percent of total billed charges,,
DIVALPROEX  SOD 500 MG TABEC,2500010125,CDM,637,RC,832712401,NDC,999,EAPG,,,,outpatient,facility,500,UN,4.69,4.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIVALPROEX  SOD 125MG SPRINKLE,2500010126,CDM,637,RC,904661561,NDC,,,,,,inpatient,facility,125,UN,2.93,2.93,0.23,2.93,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,2.93,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,
DIVALPROEX  SOD 125MG SPRINKLE,2500010126,CDM,637,RC,904661561,NDC,,,,,,outpatient,facility,125,UN,2.93,2.93,0.23,618.77,,1.71,,,percent of total billed charges,,,0.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.93,,,percent of total billed charges,,,2.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.64,,,percent of total billed charges,,,,,,,,,2.93,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,2.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,2.93,,,fee schedule,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,2.2,,,percent of total billed charges,,,2.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.06,,,percent of total billed charges,,
DIVALPROEX  SOD 125MG SPRINKLE,2500010126,CDM,637,RC,904661561,NDC,999,EAPG,,,,outpatient,facility,125,UN,2.93,2.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOCUSATE/SENNA TAB,2500010145,CDM,637,RC,536124801,NDC,,,,,,inpatient,facility,1,UN,1.86,1.86,0.15,1.86,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,
DOCUSATE/SENNA TAB,2500010145,CDM,637,RC,536124801,NDC,,,,,,outpatient,facility,1,UN,1.86,1.86,0.15,618.77,,1.09,,,percent of total billed charges,,,0.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.86,,,percent of total billed charges,,,1.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.67,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,1.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,1.86,,,fee schedule,,,1.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,1.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.31,,,percent of total billed charges,,
DOCUSATE/SENNA TAB,2500010145,CDM,637,RC,536124801,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.86,1.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOCUSATE  SOD 100 MG CAP,2500010150,CDM,637,RC,7218937760,NDC,,,,,,inpatient,facility,100,UN,1.96,1.96,0.16,1.96,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,,,,,,,1.96,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,
DOCUSATE  SOD 100 MG CAP,2500010150,CDM,637,RC,7218937760,NDC,,,,,,outpatient,facility,100,UN,1.96,1.96,0.16,618.77,,1.14,,,percent of total billed charges,,,0.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.96,,,percent of total billed charges,,,1.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.76,,,percent of total billed charges,,,,,,,,,1.96,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,1.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,1.96,,,fee schedule,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,1.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.38,,,percent of total billed charges,,
DOCUSATE  SOD 100 MG CAP,2500010150,CDM,637,RC,7218937760,NDC,999,EAPG,,,,outpatient,facility,100,UN,1.96,1.96,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOCUSATE  SOD 100 MG/10 ML UDC,2500010155,CDM,637,RC,5038377111,NDC,,,,,,inpatient,facility,10,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
DOCUSATE  SOD 100 MG/10 ML UDC,2500010155,CDM,637,RC,5038377111,NDC,,,,,,outpatient,facility,10,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
DOCUSATE  SOD 100 MG/10 ML UDC,2500010155,CDM,637,RC,5038377111,NDC,999,EAPG,,,,outpatient,facility,10,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOFETILIDE 125 MCG CAP,2500010170,CDM,637,RC,4733506186,NDC,,,,,,inpatient,facility,125,UN,28.24,28.24,2.26,28.24,,,,,,,,,,,,,,28.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.42,,,percent of total billed charges,,,,,,,,,28.24,,,percent of total billed charges,,,15.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.24,,,percent of total billed charges,,,,,,,,,,,,,,,28.24,,,percent of total billed charges,,,14.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,28.24,,,percent of total billed charges,,,28.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.83,,,percent of total billed charges,,
DOFETILIDE 125 MCG CAP,2500010170,CDM,637,RC,4733506186,NDC,,,,,,outpatient,facility,125,UN,28.24,28.24,2.26,618.77,,16.49,,,percent of total billed charges,,,5.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,28.24,,,percent of total billed charges,,,24.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,24.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,24.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,28.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,25.42,,,percent of total billed charges,,,,,,,,,28.24,,,percent of total billed charges,,,19.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.69,,,percent of total billed charges,,,,,,,,,,,,,,,15.25,,,percent of total billed charges,,,15.25,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,28.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.72,,,percent of total billed charges,,,28.24,,,percent of total billed charges,,,28.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.46,,,percent of total billed charges,,,10.7,,,percent of total billed charges,,,14.63,,,percent of total billed charges,,,,,,,,,,,,,,,5.65,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.45,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,28.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.26,,,percent of total billed charges,,,28.24,,,percent of total billed charges,,,28.24,,,percent of total billed charges,,,,,,,,,,,,,,,28.24,,,percent of total billed charges,,,28.24,,,percent of total billed charges,,,,,,,,,28.24,,,fee schedule,,,26.27,,,percent of total billed charges,,,,,,,,,,,,,,,26.27,,,percent of total billed charges,,,26.27,,,percent of total billed charges,,,26.27,,,percent of total billed charges,,,21.18,,,percent of total billed charges,,,28.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,28.24,,,percent of total billed charges,,,28.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,19.83,,,percent of total billed charges,,
DOFETILIDE 125 MCG CAP,2500010170,CDM,637,RC,4733506186,NDC,999,EAPG,,,,outpatient,facility,125,UN,28.24,28.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DONEPEZIL HCL 5 MG TAB,2500010192,CDM,637,RC,904647761,NDC,,,,,,inpatient,facility,5,UN,0.46,0.46,0.04,0.46,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,
DONEPEZIL HCL 5 MG TAB,2500010192,CDM,637,RC,904647761,NDC,,,,,,outpatient,facility,5,UN,0.46,0.46,0.04,618.77,,0.27,,,percent of total billed charges,,,0.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,0.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.41,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.17,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.46,,,fee schedule,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,0.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.32,,,percent of total billed charges,,
DONEPEZIL HCL 5 MG TAB,2500010192,CDM,637,RC,904647761,NDC,999,EAPG,,,,outpatient,facility,5,UN,0.46,0.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOPAMINE 400MG/250 ML,2500010212,CDM,636,RC,J1265,HCPCS,338100702,NDC,,,,inpatient,facility,250,UN,46.86,46.86,3.75,46.86,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.17,,,percent of total billed charges,,,,,,,,,46.86,,,percent of total billed charges,,,25.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,24.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,46.86,,,percent of total billed charges,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.91,,,percent of total billed charges,,
DOPAMINE 400MG/250 ML,2500010212,CDM,636,RC,J1265,HCPCS,338100702,NDC,,,,outpatient,facility,250,UN,46.86,46.86,0.81,618.77,,27.37,,,percent of total billed charges,,,9.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,46.86,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,42.17,,,percent of total billed charges,,,,,,,,,46.86,,,percent of total billed charges,,,31.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.43,,,percent of total billed charges,,,46.86,,,percent of total billed charges,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.61,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,24.27,,,percent of total billed charges,,,,,,,,,,,,,,,9.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,46.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.75,,,percent of total billed charges,,,46.86,,,percent of total billed charges,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,46.86,,,percent of total billed charges,,,,,,,,,46.86,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.81,,,fee schedule,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,46.86,,,percent of total billed charges,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,32.91,,,percent of total billed charges,,
DOPAMINE 400MG/250 ML,2500010212,CDM,636,RC,J1265,HCPCS,338100702,NDC,999,EAPG,,outpatient,facility,250,UN,46.86,46.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DORZOLAMIDE HCL 2  OPH 10 ML,2500010220,CDM,637,RC,6131401910,NDC,,,,,,inpatient,facility,10,UN,220.28,220.28,17.62,220.28,,,,,,,,,,,,,,220.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.25,,,percent of total billed charges,,,,,,,,,220.28,,,percent of total billed charges,,,121.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.28,,,percent of total billed charges,,,,,,,,,,,,,,,220.28,,,percent of total billed charges,,,114.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.62,,,percent of total billed charges,,,220.28,,,percent of total billed charges,,,220.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,220.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.68,,,percent of total billed charges,,
DORZOLAMIDE HCL 2  OPH 10 ML,2500010220,CDM,637,RC,6131401910,NDC,,,,,,outpatient,facility,10,UN,220.28,220.28,17.62,618.77,,128.64,,,percent of total billed charges,,,42.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,220.28,,,percent of total billed charges,,,193.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,193.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,193.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,220.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,80.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,198.25,,,percent of total billed charges,,,,,,,,,220.28,,,percent of total billed charges,,,149.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.18,,,percent of total billed charges,,,,,,,,,,,,,,,118.95,,,percent of total billed charges,,,118.95,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,220.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.85,,,percent of total billed charges,,,220.28,,,percent of total billed charges,,,220.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.41,,,percent of total billed charges,,,83.44,,,percent of total billed charges,,,114.08,,,percent of total billed charges,,,,,,,,,,,,,,,44.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,81.5,,,percent of total billed charges,,,81.5,,,percent of total billed charges,,,220.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,220.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.62,,,percent of total billed charges,,,220.28,,,percent of total billed charges,,,220.28,,,percent of total billed charges,,,,,,,,,,,,,,,220.28,,,percent of total billed charges,,,220.28,,,percent of total billed charges,,,,,,,,,220.28,,,fee schedule,,,204.9,,,percent of total billed charges,,,,,,,,,,,,,,,204.9,,,percent of total billed charges,,,204.9,,,percent of total billed charges,,,204.9,,,percent of total billed charges,,,165.21,,,percent of total billed charges,,,220.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,220.28,,,percent of total billed charges,,,220.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,154.68,,,percent of total billed charges,,
DORZOLAMIDE HCL 2  OPH 10 ML,2500010220,CDM,637,RC,6131401910,NDC,999,EAPG,,,,outpatient,facility,10,UN,220.28,220.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DORZOLAMIDE/TIMOL 2 -0.5  10ML,2500010226,CDM,637,RC,2420848610,NDC,,,,,,inpatient,facility,10,UN,222.72,222.72,17.82,222.72,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.45,,,percent of total billed charges,,,,,,,,,222.72,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,203.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,116.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.39,,,percent of total billed charges,,
DORZOLAMIDE/TIMOL 2 -0.5  10ML,2500010226,CDM,637,RC,2420848610,NDC,,,,,,outpatient,facility,10,UN,222.72,222.72,17.82,618.77,,130.07,,,percent of total billed charges,,,43.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,222.72,,,percent of total billed charges,,,196.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,196.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,196.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,81.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,200.45,,,percent of total billed charges,,,,,,,,,222.72,,,percent of total billed charges,,,150.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.05,,,percent of total billed charges,,,,,,,,,,,,,,,120.27,,,percent of total billed charges,,,120.27,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,116.13,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.27,,,percent of total billed charges,,,84.37,,,percent of total billed charges,,,115.35,,,percent of total billed charges,,,,,,,,,,,,,,,44.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,82.41,,,percent of total billed charges,,,82.41,,,percent of total billed charges,,,222.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,222.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.82,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,,,,,,,222.72,,,fee schedule,,,207.17,,,percent of total billed charges,,,,,,,,,,,,,,,207.17,,,percent of total billed charges,,,207.17,,,percent of total billed charges,,,207.17,,,percent of total billed charges,,,167.04,,,percent of total billed charges,,,222.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,222.72,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,156.39,,,percent of total billed charges,,
DORZOLAMIDE/TIMOL 2 -0.5  10ML,2500010226,CDM,637,RC,2420848610,NDC,999,EAPG,,,,outpatient,facility,10,UN,222.72,222.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXAZOSIN MESY 1 MG TAB,2500010240,CDM,637,RC,1672921101,NDC,,,,,,inpatient,facility,1,UN,4.45,4.45,0.36,4.45,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4,,,percent of total billed charges,,,,,,,,,4.45,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,2.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,
DOXAZOSIN MESY 1 MG TAB,2500010240,CDM,637,RC,1672921101,NDC,,,,,,outpatient,facility,1,UN,4.45,4.45,0.36,618.77,,2.6,,,percent of total billed charges,,,0.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.45,,,percent of total billed charges,,,3.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4,,,percent of total billed charges,,,,,,,,,4.45,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.42,,,percent of total billed charges,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,1.69,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,4.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.36,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,4.45,,,fee schedule,,,4.14,,,percent of total billed charges,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,,4.14,,,percent of total billed charges,,,4.14,,,percent of total billed charges,,,3.34,,,percent of total billed charges,,,4.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.45,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.12,,,percent of total billed charges,,
DOXAZOSIN MESY 1 MG TAB,2500010240,CDM,637,RC,1672921101,NDC,999,EAPG,,,,outpatient,facility,1,UN,4.45,4.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXAZOSIN MESY 2 MG TAB,2500010242,CDM,637,RC,1672941401,NDC,,,,,,inpatient,facility,2,UN,4.46,4.46,0.36,4.46,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,,,,,,,4.46,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,
DOXAZOSIN MESY 2 MG TAB,2500010242,CDM,637,RC,1672941401,NDC,,,,,,outpatient,facility,2,UN,4.46,4.46,0.36,618.77,,2.6,,,percent of total billed charges,,,0.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.46,,,percent of total billed charges,,,3.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.01,,,percent of total billed charges,,,,,,,,,4.46,,,percent of total billed charges,,,3.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,1.69,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,4.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.36,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,4.46,,,fee schedule,,,4.15,,,percent of total billed charges,,,,,,,,,,,,,,,4.15,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,3.34,,,percent of total billed charges,,,4.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.13,,,percent of total billed charges,,
DOXAZOSIN MESY 2 MG TAB,2500010242,CDM,637,RC,1672941401,NDC,999,EAPG,,,,outpatient,facility,2,UN,4.46,4.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXAZOSIN MESY 4 MG TAB,2500010244,CDM,637,RC,1672921301,NDC,,,,,,inpatient,facility,4,UN,4.68,4.68,0.37,4.68,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.29,,,percent of total billed charges,,
DOXAZOSIN MESY 4 MG TAB,2500010244,CDM,637,RC,1672921301,NDC,,,,,,outpatient,facility,4,UN,4.68,4.68,0.37,618.77,,2.73,,,percent of total billed charges,,,0.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.68,,,percent of total billed charges,,,4.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.21,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.59,,,percent of total billed charges,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,2.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.44,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.73,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,4.68,,,fee schedule,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,4.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.29,,,percent of total billed charges,,
DOXAZOSIN MESY 4 MG TAB,2500010244,CDM,637,RC,1672921301,NDC,999,EAPG,,,,outpatient,facility,4,UN,4.68,4.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXEPIN HCL 10 MG CAP,2500010251,CDM,637,RC,904705261,NDC,,,,,,inpatient,facility,10,UN,2.01,2.01,0.16,2.01,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,
DOXEPIN HCL 10 MG CAP,2500010251,CDM,637,RC,904705261,NDC,,,,,,outpatient,facility,10,UN,2.01,2.01,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.01,,,percent of total billed charges,,,1.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.81,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,2.01,,,fee schedule,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,2.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.41,,,percent of total billed charges,,
DOXEPIN HCL 10 MG CAP,2500010251,CDM,637,RC,904705261,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.01,2.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXEPIN HCL 25 MG CAP,2500010253,CDM,637,RC,904705361,NDC,,,,,,inpatient,facility,25,UN,2.64,2.64,0.21,2.64,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,
DOXEPIN HCL 25 MG CAP,2500010253,CDM,637,RC,904705361,NDC,,,,,,outpatient,facility,25,UN,2.64,2.64,0.21,618.77,,1.54,,,percent of total billed charges,,,0.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.64,,,percent of total billed charges,,,2.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.38,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.98,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,2.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,2.64,,,fee schedule,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,2.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.85,,,percent of total billed charges,,
DOXEPIN HCL 25 MG CAP,2500010253,CDM,637,RC,904705361,NDC,999,EAPG,,,,outpatient,facility,25,UN,2.64,2.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXYCYCLINE HYCLATE 100 MG TAB,2500010272,CDM,637,RC,904043006,NDC,,,,,,inpatient,facility,100,UN,7.22,7.22,0.58,7.22,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,,,,,,,7.22,,,percent of total billed charges,,,4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,
DOXYCYCLINE HYCLATE 100 MG TAB,2500010272,CDM,637,RC,904043006,NDC,,,,,,outpatient,facility,100,UN,7.22,7.22,0.58,618.77,,4.22,,,percent of total billed charges,,,1.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.22,,,percent of total billed charges,,,6.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.5,,,percent of total billed charges,,,,,,,,,7.22,,,percent of total billed charges,,,4.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,3.9,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.49,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,3.74,,,percent of total billed charges,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.67,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,7.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.58,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,,,,,,,7.22,,,fee schedule,,,6.72,,,percent of total billed charges,,,,,,,,,,,,,,,6.72,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,5.42,,,percent of total billed charges,,,7.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.22,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.07,,,percent of total billed charges,,
DOXYCYCLINE HYCLATE 100 MG TAB,2500010272,CDM,637,RC,904043006,NDC,999,EAPG,,,,outpatient,facility,100,UN,7.22,7.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXYCYCLINE HYCLATE 100 MG INJ,2500010274,CDM,250,RC,J3490,HCPCS,6838291010,NDC,,,,inpatient,facility,100,UN,99.66,99.66,7.97,99.66,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.69,,,percent of total billed charges,,,,,,,,,99.66,,,percent of total billed charges,,,55.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,51.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.97,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.98,,,percent of total billed charges,,
DOXYCYCLINE HYCLATE 100 MG INJ,2500010274,CDM,250,RC,J3490,HCPCS,6838291010,NDC,,,,outpatient,facility,100,UN,99.66,99.66,1.2,618.77,,58.2,,,percent of total billed charges,,,19.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,99.66,,,percent of total billed charges,,,87.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,87.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,87.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,36.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,89.69,,,percent of total billed charges,,,,,,,,,99.66,,,percent of total billed charges,,,67.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.54,,,percent of total billed charges,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.96,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.74,,,percent of total billed charges,,,37.75,,,percent of total billed charges,,,51.61,,,percent of total billed charges,,,,,,,,,,,,,,,19.93,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,99.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,99.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.97,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,,,,,,,99.66,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,74.75,,,percent of total billed charges,,,99.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,99.66,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,69.98,,,percent of total billed charges,,
DOXYCYCLINE HYCLATE 100 MG INJ,2500010274,CDM,250,RC,J3490,HCPCS,6838291010,NDC,435,EAPG,,outpatient,facility,100,UN,99.66,99.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DRONABINOL 2.5 MG CAP,2500010280,CDM,636,RC,Q0167,HCPCS,904714461,NDC,,,,inpatient,facility,2.5,UN,15.58,15.58,1.25,15.58,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.02,,,percent of total billed charges,,,,,,,,,15.58,,,percent of total billed charges,,,8.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,8.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.94,,,percent of total billed charges,,
DRONABINOL 2.5 MG CAP,2500010280,CDM,636,RC,Q0167,HCPCS,904714461,NDC,,,,outpatient,facility,2.5,UN,15.58,15.58,1.25,618.77,,9.1,,,percent of total billed charges,,,3.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,15.58,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,14.02,,,percent of total billed charges,,,,,,,,,15.58,,,percent of total billed charges,,,10.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.12,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.84,,,percent of total billed charges,,,5.9,,,percent of total billed charges,,,8.07,,,percent of total billed charges,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,15.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.25,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,,,,,,,15.58,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.79,,,fee schedule,,,15.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,15.58,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.79,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.94,,,percent of total billed charges,,
DRONABINOL 2.5 MG CAP,2500010280,CDM,636,RC,Q0167,HCPCS,904714461,NDC,999,EAPG,,outpatient,facility,2.5,UN,15.58,15.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EFAVIRENZ 200 MG CAPSULE,2500010362,CDM,637,RC,6498040709,NDC,,,,,,inpatient,facility,200,UN,38.84,38.84,3.11,38.84,,,,,,,,,,,,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.96,,,percent of total billed charges,,,,,,,,,38.84,,,percent of total billed charges,,,21.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,38.84,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.11,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.27,,,percent of total billed charges,,
EFAVIRENZ 200 MG CAPSULE,2500010362,CDM,637,RC,6498040709,NDC,,,,,,outpatient,facility,200,UN,38.84,38.84,3.11,618.77,,22.68,,,percent of total billed charges,,,7.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,38.84,,,percent of total billed charges,,,34.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,34.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,34.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,14.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,34.96,,,percent of total billed charges,,,,,,,,,38.84,,,percent of total billed charges,,,26.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.83,,,percent of total billed charges,,,,,,,,,,,,,,,20.97,,,percent of total billed charges,,,20.97,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.25,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.52,,,percent of total billed charges,,,14.71,,,percent of total billed charges,,,20.12,,,percent of total billed charges,,,,,,,,,,,,,,,7.77,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,14.37,,,percent of total billed charges,,,14.37,,,percent of total billed charges,,,38.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,38.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.11,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,38.84,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,,,,,,,38.84,,,fee schedule,,,36.13,,,percent of total billed charges,,,,,,,,,,,,,,,36.13,,,percent of total billed charges,,,36.13,,,percent of total billed charges,,,36.13,,,percent of total billed charges,,,29.13,,,percent of total billed charges,,,38.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,38.84,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,27.27,,,percent of total billed charges,,
EFAVIRENZ 200 MG CAPSULE,2500010362,CDM,637,RC,6498040709,NDC,999,EAPG,,,,outpatient,facility,200,UN,38.84,38.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENALAPRILAT 1.25 MG/ML 2ML INJ,2500010437,CDM,250,RC,J3490,HCPCS,143978610,NDC,,,,inpatient,facility,2,UN,31.28,31.28,2.5,31.28,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.15,,,percent of total billed charges,,,,,,,,,31.28,,,percent of total billed charges,,,17.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,16.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.96,,,percent of total billed charges,,
ENALAPRILAT 1.25 MG/ML 2ML INJ,2500010437,CDM,250,RC,J3490,HCPCS,143978610,NDC,,,,outpatient,facility,2,UN,31.28,31.28,1.2,618.77,,18.27,,,percent of total billed charges,,,6.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,31.28,,,percent of total billed charges,,,27.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,27.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,27.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,28.15,,,percent of total billed charges,,,,,,,,,31.28,,,percent of total billed charges,,,21.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.02,,,percent of total billed charges,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.31,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.77,,,percent of total billed charges,,,11.85,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,31.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.5,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,31.28,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,23.46,,,percent of total billed charges,,,31.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,21.96,,,percent of total billed charges,,
ENALAPRILAT 1.25 MG/ML 2ML INJ,2500010437,CDM,250,RC,J3490,HCPCS,143978610,NDC,435,EAPG,,outpatient,facility,2,UN,31.28,31.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENTACAPONE 200 MG TAB,2500010450,CDM,637,RC,6586265401,NDC,,,,,,inpatient,facility,200,UN,14.98,14.98,1.2,14.98,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.48,,,percent of total billed charges,,,,,,,,,14.98,,,percent of total billed charges,,,8.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,7.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.52,,,percent of total billed charges,,
ENTACAPONE 200 MG TAB,2500010450,CDM,637,RC,6586265401,NDC,,,,,,outpatient,facility,200,UN,14.98,14.98,1.2,618.77,,8.75,,,percent of total billed charges,,,2.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.98,,,percent of total billed charges,,,13.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,13.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,13.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.48,,,percent of total billed charges,,,,,,,,,14.98,,,percent of total billed charges,,,10.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.5,,,percent of total billed charges,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.81,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.38,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,7.76,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.54,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,14.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.2,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,14.98,,,fee schedule,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,11.23,,,percent of total billed charges,,,14.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.52,,,percent of total billed charges,,
ENTACAPONE 200 MG TAB,2500010450,CDM,637,RC,6586265401,NDC,999,EAPG,,,,outpatient,facility,200,UN,14.98,14.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ERGOCALCIFEROL 50000 IU CAP,2500010530,CDM,637,RC,6438073706,NDC,,,,,,inpatient,facility,50000,UN,6.5,6.5,0.52,6.5,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.85,,,percent of total billed charges,,,,,,,,,6.5,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.56,,,percent of total billed charges,,
ERGOCALCIFEROL 50000 IU CAP,2500010530,CDM,637,RC,6438073706,NDC,,,,,,outpatient,facility,50000,UN,6.5,6.5,0.52,618.77,,3.8,,,percent of total billed charges,,,1.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.5,,,percent of total billed charges,,,5.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.85,,,percent of total billed charges,,,,,,,,,6.5,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.99,,,percent of total billed charges,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.4,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,6.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.52,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,,,,,,,6.5,,,fee schedule,,,6.05,,,percent of total billed charges,,,,,,,,,,,,,,,6.05,,,percent of total billed charges,,,6.05,,,percent of total billed charges,,,6.05,,,percent of total billed charges,,,4.88,,,percent of total billed charges,,,6.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.5,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.56,,,percent of total billed charges,,
ERGOCALCIFEROL 50000 IU CAP,2500010530,CDM,637,RC,6438073706,NDC,999,EAPG,,,,outpatient,facility,50000,UN,6.5,6.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ERYTHROMYCIN OPH OINT 1 GM PKT,2500010602,CDM,637,RC,574402450,NDC,,,,,,inpatient,facility,1,UN,23.93,23.93,1.91,23.93,,,,,,,,,,,,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.54,,,percent of total billed charges,,,,,,,,,23.93,,,percent of total billed charges,,,13.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,23.93,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.8,,,percent of total billed charges,,
ERYTHROMYCIN OPH OINT 1 GM PKT,2500010602,CDM,637,RC,574402450,NDC,,,,,,outpatient,facility,1,UN,23.93,23.93,1.91,618.77,,13.98,,,percent of total billed charges,,,4.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,23.93,,,percent of total billed charges,,,21.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,21.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,21.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,21.54,,,percent of total billed charges,,,,,,,,,23.93,,,percent of total billed charges,,,16.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,12.92,,,percent of total billed charges,,,12.92,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.48,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.19,,,percent of total billed charges,,,9.06,,,percent of total billed charges,,,12.39,,,percent of total billed charges,,,,,,,,,,,,,,,4.79,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.85,,,percent of total billed charges,,,8.85,,,percent of total billed charges,,,23.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.91,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,23.93,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,23.93,,,fee schedule,,,22.26,,,percent of total billed charges,,,,,,,,,,,,,,,22.26,,,percent of total billed charges,,,22.26,,,percent of total billed charges,,,22.26,,,percent of total billed charges,,,17.95,,,percent of total billed charges,,,23.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,23.93,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,16.8,,,percent of total billed charges,,
ERYTHROMYCIN OPH OINT 1 GM PKT,2500010602,CDM,637,RC,574402450,NDC,999,EAPG,,,,outpatient,facility,1,UN,23.93,23.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESMOLOL HCL 10 MG/ML 10 ML INJ,2500010640,CDM,250,RC,J3490,HCPCS,5515019410,NDC,,,,inpatient,facility,10,ML,29.04,29.04,2.32,29.04,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.14,,,percent of total billed charges,,,,,,,,,29.04,,,percent of total billed charges,,,16.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,15.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,29.04,,,percent of total billed charges,,,29.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.39,,,percent of total billed charges,,
ESMOLOL HCL 10 MG/ML 10 ML INJ,2500010640,CDM,250,RC,J3490,HCPCS,5515019410,NDC,,,,outpatient,facility,10,ML,29.04,29.04,1.2,618.77,,16.96,,,percent of total billed charges,,,5.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,29.04,,,percent of total billed charges,,,25.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,25.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,25.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26.14,,,percent of total billed charges,,,,,,,,,29.04,,,percent of total billed charges,,,19.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.3,,,percent of total billed charges,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,29.04,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,29.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.14,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.07,,,percent of total billed charges,,,11,,,percent of total billed charges,,,15.04,,,percent of total billed charges,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,29.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.32,,,percent of total billed charges,,,29.04,,,percent of total billed charges,,,29.04,,,percent of total billed charges,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,29.04,,,percent of total billed charges,,,,,,,,,29.04,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,21.78,,,percent of total billed charges,,,29.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,29.04,,,percent of total billed charges,,,29.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.39,,,percent of total billed charges,,
ESMOLOL HCL 10 MG/ML 10 ML INJ,2500010640,CDM,250,RC,J3490,HCPCS,5515019410,NDC,435,EAPG,,outpatient,facility,10,ML,29.04,29.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESMOLOL 2500 MG/250 ML PREMIX,2500010654,CDM,250,RC,J3490,HCPCS,6745765725,NDC,,,,inpatient,facility,250,UN,1664.98,1664.98,133.2,1664.98,,,,,,,,,,,,,,1664.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1498.48,,,percent of total billed charges,,,,,,,,,1664.98,,,percent of total billed charges,,,921.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1519.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1664.98,,,percent of total billed charges,,,,,,,,,,,,,,,1664.98,,,percent of total billed charges,,,868.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,333,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.2,,,percent of total billed charges,,,1664.98,,,percent of total billed charges,,,1664.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1664.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1169.15,,,percent of total billed charges,,
ESMOLOL 2500 MG/250 ML PREMIX,2500010654,CDM,250,RC,J3490,HCPCS,6745765725,NDC,,,,outpatient,facility,250,UN,1664.98,1664.98,1.2,1664.98,,972.35,,,percent of total billed charges,,,324.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1664.98,,,percent of total billed charges,,,1465.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1465.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1465.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1664.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,609.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1498.48,,,percent of total billed charges,,,,,,,,,1664.98,,,percent of total billed charges,,,1127.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1278.7,,,percent of total billed charges,,,,,,,,,,,,,,,1664.98,,,percent of total billed charges,,,1664.98,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1664.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,868.12,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1265.38,,,percent of total billed charges,,,630.69,,,percent of total billed charges,,,862.29,,,percent of total billed charges,,,,,,,,,,,,,,,333,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,1664.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1664.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,133.2,,,percent of total billed charges,,,1664.98,,,percent of total billed charges,,,1664.98,,,percent of total billed charges,,,,,,,,,,,,,,,1664.98,,,percent of total billed charges,,,1664.98,,,percent of total billed charges,,,,,,,,,1664.98,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1248.74,,,percent of total billed charges,,,1664.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1664.98,,,percent of total billed charges,,,1664.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1169.15,,,percent of total billed charges,,
ESMOLOL 2500 MG/250 ML PREMIX,2500010654,CDM,250,RC,J3490,HCPCS,6745765725,NDC,435,EAPG,,outpatient,facility,250,UN,1664.98,1664.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESTRADIOL 0.05 MG/24 HR 3D PAT,2500010660,CDM,637,RC,781713354,NDC,,,,,,inpatient,facility,1,UN,76.59,76.59,6.13,76.59,,,,,,,,,,,,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.93,,,percent of total billed charges,,,,,,,,,76.59,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,76.59,,,percent of total billed charges,,,39.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.78,,,percent of total billed charges,,
ESTRADIOL 0.05 MG/24 HR 3D PAT,2500010660,CDM,637,RC,781713354,NDC,,,,,,outpatient,facility,1,UN,76.59,76.59,6.13,618.77,,44.73,,,percent of total billed charges,,,14.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,76.59,,,percent of total billed charges,,,67.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,67.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,67.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,28.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,68.93,,,percent of total billed charges,,,,,,,,,76.59,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.82,,,percent of total billed charges,,,,,,,,,,,,,,,41.36,,,percent of total billed charges,,,41.36,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.93,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.21,,,percent of total billed charges,,,29.01,,,percent of total billed charges,,,39.67,,,percent of total billed charges,,,,,,,,,,,,,,,15.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,28.34,,,percent of total billed charges,,,28.34,,,percent of total billed charges,,,76.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,76.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.13,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,76.59,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,,,,,,,76.59,,,fee schedule,,,71.24,,,percent of total billed charges,,,,,,,,,,,,,,,71.24,,,percent of total billed charges,,,71.24,,,percent of total billed charges,,,71.24,,,percent of total billed charges,,,57.44,,,percent of total billed charges,,,76.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,76.59,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,53.78,,,percent of total billed charges,,
ESTRADIOL 0.05 MG/24 HR 3D PAT,2500010660,CDM,637,RC,781713354,NDC,999,EAPG,,,,outpatient,facility,1,UN,76.59,76.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESTRADIOL 1 MG TAB,2500010667,CDM,637,RC,555088602,NDC,,,,,,inpatient,facility,1,UN,2.24,2.24,0.18,2.24,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,
ESTRADIOL 1 MG TAB,2500010667,CDM,637,RC,555088602,NDC,,,,,,outpatient,facility,1,UN,2.24,2.24,0.18,618.77,,1.31,,,percent of total billed charges,,,0.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.24,,,percent of total billed charges,,,1.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.02,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,2.24,,,fee schedule,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,2.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.57,,,percent of total billed charges,,
ESTRADIOL 1 MG TAB,2500010667,CDM,637,RC,555088602,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.24,2.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESTROGEN CONJ 0.3 MG TAB,2500010710,CDM,637,RC,46110081,NDC,,,,,,inpatient,facility,0.3,UN,22.11,22.11,1.77,22.11,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.9,,,percent of total billed charges,,,,,,,,,22.11,,,percent of total billed charges,,,12.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,11.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.53,,,percent of total billed charges,,
ESTROGEN CONJ 0.3 MG TAB,2500010710,CDM,637,RC,46110081,NDC,,,,,,outpatient,facility,0.3,UN,22.11,22.11,1.77,618.77,,12.91,,,percent of total billed charges,,,4.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,22.11,,,percent of total billed charges,,,19.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,19.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,19.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,19.9,,,percent of total billed charges,,,,,,,,,22.11,,,percent of total billed charges,,,14.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.98,,,percent of total billed charges,,,,,,,,,,,,,,,11.94,,,percent of total billed charges,,,11.94,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.53,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.8,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.18,,,percent of total billed charges,,,8.18,,,percent of total billed charges,,,22.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.77,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,22.11,,,fee schedule,,,20.57,,,percent of total billed charges,,,,,,,,,,,,,,,20.57,,,percent of total billed charges,,,20.57,,,percent of total billed charges,,,20.57,,,percent of total billed charges,,,16.58,,,percent of total billed charges,,,22.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,15.53,,,percent of total billed charges,,
ESTROGEN CONJ 0.3 MG TAB,2500010710,CDM,637,RC,46110081,NDC,999,EAPG,,,,outpatient,facility,0.3,UN,22.11,22.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ETHACRYNIC ACID 25 MG TAB,2500010740,CDM,637,RC,6818015901,NDC,,,,,,inpatient,facility,25,UN,79.04,79.04,6.32,79.04,,,,,,,,,,,,,,79.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.14,,,percent of total billed charges,,,,,,,,,79.04,,,percent of total billed charges,,,43.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.04,,,percent of total billed charges,,,,,,,,,,,,,,,79.04,,,percent of total billed charges,,,41.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.32,,,percent of total billed charges,,,79.04,,,percent of total billed charges,,,79.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.5,,,percent of total billed charges,,
ETHACRYNIC ACID 25 MG TAB,2500010740,CDM,637,RC,6818015901,NDC,,,,,,outpatient,facility,25,UN,79.04,79.04,6.32,618.77,,46.16,,,percent of total billed charges,,,15.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,79.04,,,percent of total billed charges,,,69.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,69.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,69.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,79.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,28.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,71.14,,,percent of total billed charges,,,,,,,,,79.04,,,percent of total billed charges,,,53.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.7,,,percent of total billed charges,,,,,,,,,,,,,,,42.68,,,percent of total billed charges,,,42.68,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,79.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.21,,,percent of total billed charges,,,79.04,,,percent of total billed charges,,,79.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.07,,,percent of total billed charges,,,29.94,,,percent of total billed charges,,,40.93,,,percent of total billed charges,,,,,,,,,,,,,,,15.81,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,29.24,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,79.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,79.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.32,,,percent of total billed charges,,,79.04,,,percent of total billed charges,,,79.04,,,percent of total billed charges,,,,,,,,,,,,,,,79.04,,,percent of total billed charges,,,79.04,,,percent of total billed charges,,,,,,,,,79.04,,,fee schedule,,,73.52,,,percent of total billed charges,,,,,,,,,,,,,,,73.52,,,percent of total billed charges,,,73.52,,,percent of total billed charges,,,73.52,,,percent of total billed charges,,,59.28,,,percent of total billed charges,,,79.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,79.04,,,percent of total billed charges,,,79.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,55.5,,,percent of total billed charges,,
ETHACRYNIC ACID 25 MG TAB,2500010740,CDM,637,RC,6818015901,NDC,999,EAPG,,,,outpatient,facility,25,UN,79.04,79.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ETOMIDATE 2 MG/ML 10 ML AMP,2500010860,CDM,250,RC,J3490,HCPCS,5515022110,NDC,,,,inpatient,facility,10,UN,31.68,31.68,2.53,31.68,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,,,,,,,31.68,,,percent of total billed charges,,,17.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,16.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.25,,,percent of total billed charges,,
ETOMIDATE 2 MG/ML 10 ML AMP,2500010860,CDM,250,RC,J3490,HCPCS,5515022110,NDC,,,,outpatient,facility,10,UN,31.68,31.68,1.2,618.77,,18.5,,,percent of total billed charges,,,6.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,31.68,,,percent of total billed charges,,,27.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,27.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,27.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,28.51,,,percent of total billed charges,,,,,,,,,31.68,,,percent of total billed charges,,,21.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.33,,,percent of total billed charges,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.52,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.08,,,percent of total billed charges,,,12,,,percent of total billed charges,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,31.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.53,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,,,,,,,31.68,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,23.76,,,percent of total billed charges,,,31.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,31.68,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,22.25,,,percent of total billed charges,,
ETOMIDATE 2 MG/ML 10 ML AMP,2500010860,CDM,250,RC,J3490,HCPCS,5515022110,NDC,435,EAPG,,outpatient,facility,10,UN,31.68,31.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FAMOTIDINE 20 MG TAB,2500010900,CDM,637,RC,172572860,NDC,,,,,,inpatient,facility,20,UN,7.98,7.98,0.64,7.98,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.18,,,percent of total billed charges,,,,,,,,,7.98,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.6,,,percent of total billed charges,,
FAMOTIDINE 20 MG TAB,2500010900,CDM,637,RC,172572860,NDC,,,,,,outpatient,facility,20,UN,7.98,7.98,0.64,618.77,,4.66,,,percent of total billed charges,,,1.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.98,,,percent of total billed charges,,,7.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.18,,,percent of total billed charges,,,,,,,,,7.98,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,4.31,,,percent of total billed charges,,,4.31,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.06,,,percent of total billed charges,,,3.02,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.95,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,7.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.64,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,,,,,,,7.98,,,fee schedule,,,7.42,,,percent of total billed charges,,,,,,,,,,,,,,,7.42,,,percent of total billed charges,,,7.42,,,percent of total billed charges,,,7.42,,,percent of total billed charges,,,5.99,,,percent of total billed charges,,,7.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.98,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.6,,,percent of total billed charges,,
FAMOTIDINE 20 MG TAB,2500010900,CDM,637,RC,172572860,NDC,999,EAPG,,,,outpatient,facility,20,UN,7.98,7.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FAT EMULSION IV 20  250 ML,2500010912,CDM,250,RC,B4185,HCPCS,6332382074,NDC,,,,inpatient,facility,250,UN,85.8,85.8,6.86,85.8,,,,,,,,,,,,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.22,,,percent of total billed charges,,,,,,,,,85.8,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,85.8,,,percent of total billed charges,,,44.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.25,,,percent of total billed charges,,
FAT EMULSION IV 20  250 ML,2500010912,CDM,250,RC,B4185,HCPCS,6332382074,NDC,,,,outpatient,facility,250,UN,85.8,85.8,5.41,618.77,,50.11,,,percent of total billed charges,,,16.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,85.8,,,percent of total billed charges,,,5.61,,,fee schedule,,,5.41,,,fee schedule,,,,,,,,,5.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,31.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,77.22,,,percent of total billed charges,,,,,,,,,85.8,,,percent of total billed charges,,,58.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,44.74,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.21,,,percent of total billed charges,,,32.5,,,percent of total billed charges,,,44.44,,,percent of total billed charges,,,,,,,,,,,,,,,17.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,33.61,,,fee schedule,,,14.99,,,fee schedule,,,85.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,85.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.86,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,85.8,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,,,,,,,16.29,,,fee schedule,,,33.04,,,fee schedule,,,,,,,,,,,,,,,29.06,,,fee schedule,,,38.74,,,fee schedule,,,21.48,,,fee schedule,,,64.35,,,percent of total billed charges,,,85.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,85.8,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,60.25,,,percent of total billed charges,,
FAT EMULSION IV 20  250 ML,2500010912,CDM,250,RC,B4185,HCPCS,6332382074,NDC,999,EAPG,,outpatient,facility,250,UN,85.8,85.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENOFIBRATE 54 MG TAB,2500010942,CDM,637,RC,7075621490,NDC,,,,,,inpatient,facility,54,UN,2.61,2.61,0.21,2.61,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,2.61,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,
FENOFIBRATE 54 MG TAB,2500010942,CDM,637,RC,7075621490,NDC,,,,,,outpatient,facility,54,UN,2.61,2.61,0.21,618.77,,1.52,,,percent of total billed charges,,,0.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.61,,,percent of total billed charges,,,2.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.35,,,percent of total billed charges,,,,,,,,,2.61,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.97,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,2.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,2.61,,,fee schedule,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,2.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.83,,,percent of total billed charges,,
FENOFIBRATE 54 MG TAB,2500010942,CDM,637,RC,7075621490,NDC,999,EAPG,,,,outpatient,facility,54,UN,2.61,2.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENOFIBRATE 160 MG,2500010944,CDM,637,RC,7075621590,NDC,,,,,,inpatient,facility,160,UN,7.85,7.85,0.63,7.85,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.06,,,percent of total billed charges,,,,,,,,,7.85,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,
FENOFIBRATE 160 MG,2500010944,CDM,637,RC,7075621590,NDC,,,,,,outpatient,facility,160,UN,7.85,7.85,0.63,618.77,,4.58,,,percent of total billed charges,,,1.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.85,,,percent of total billed charges,,,6.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.06,,,percent of total billed charges,,,,,,,,,7.85,,,percent of total billed charges,,,5.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.03,,,percent of total billed charges,,,,,,,,,,,,,,,4.24,,,percent of total billed charges,,,4.24,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,4.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,7.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.63,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,7.85,,,fee schedule,,,7.3,,,percent of total billed charges,,,,,,,,,,,,,,,7.3,,,percent of total billed charges,,,7.3,,,percent of total billed charges,,,7.3,,,percent of total billed charges,,,5.89,,,percent of total billed charges,,,7.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.85,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.51,,,percent of total billed charges,,
FENOFIBRATE 160 MG,2500010944,CDM,637,RC,7075621590,NDC,999,EAPG,,,,outpatient,facility,160,UN,7.85,7.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL TRANSDERM 25 MCG/HR,2500010983,CDM,637,RC,6050570812,NDC,,,,,,inpatient,facility,1,UN,70.19,70.19,5.62,70.19,,,,,,,,,,,,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.17,,,percent of total billed charges,,,,,,,,,70.19,,,percent of total billed charges,,,38.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,70.19,,,percent of total billed charges,,,36.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.62,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,
FENTANYL TRANSDERM 25 MCG/HR,2500010983,CDM,637,RC,6050570812,NDC,,,,,,outpatient,facility,1,UN,70.19,70.19,5.62,618.77,,40.99,,,percent of total billed charges,,,13.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,70.19,,,percent of total billed charges,,,61.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,61.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,61.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,25.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,63.17,,,percent of total billed charges,,,,,,,,,70.19,,,percent of total billed charges,,,47.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.91,,,percent of total billed charges,,,,,,,,,,,,,,,37.9,,,percent of total billed charges,,,37.9,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.6,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.34,,,percent of total billed charges,,,26.59,,,percent of total billed charges,,,36.35,,,percent of total billed charges,,,,,,,,,,,,,,,14.04,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,25.97,,,percent of total billed charges,,,25.97,,,percent of total billed charges,,,70.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,70.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.62,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,70.19,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,,,,,,,70.19,,,fee schedule,,,65.29,,,percent of total billed charges,,,,,,,,,,,,,,,65.29,,,percent of total billed charges,,,65.29,,,percent of total billed charges,,,65.29,,,percent of total billed charges,,,52.64,,,percent of total billed charges,,,70.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,70.19,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,49.29,,,percent of total billed charges,,
FENTANYL TRANSDERM 25 MCG/HR,2500010983,CDM,637,RC,6050570812,NDC,999,EAPG,,,,outpatient,facility,1,UN,70.19,70.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL TRANSDERM 50 MCG/HR,2500010985,CDM,637,RC,6050570822,NDC,,,,,,inpatient,facility,1,UN,128.3,128.3,10.26,128.3,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.47,,,percent of total billed charges,,,,,,,,,128.3,,,percent of total billed charges,,,71.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,66.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.26,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.09,,,percent of total billed charges,,
FENTANYL TRANSDERM 50 MCG/HR,2500010985,CDM,637,RC,6050570822,NDC,,,,,,outpatient,facility,1,UN,128.3,128.3,10.26,618.77,,74.93,,,percent of total billed charges,,,25.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,128.3,,,percent of total billed charges,,,112.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,112.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,112.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,46.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,115.47,,,percent of total billed charges,,,,,,,,,128.3,,,percent of total billed charges,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.53,,,percent of total billed charges,,,,,,,,,,,,,,,69.28,,,percent of total billed charges,,,69.28,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.9,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.51,,,percent of total billed charges,,,48.6,,,percent of total billed charges,,,66.45,,,percent of total billed charges,,,,,,,,,,,,,,,25.66,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,47.47,,,percent of total billed charges,,,47.47,,,percent of total billed charges,,,128.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,128.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.26,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,,,,,,,128.3,,,fee schedule,,,119.34,,,percent of total billed charges,,,,,,,,,,,,,,,119.34,,,percent of total billed charges,,,119.34,,,percent of total billed charges,,,119.34,,,percent of total billed charges,,,96.23,,,percent of total billed charges,,,128.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,128.3,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,90.09,,,percent of total billed charges,,
FENTANYL TRANSDERM 50 MCG/HR,2500010985,CDM,637,RC,6050570822,NDC,999,EAPG,,,,outpatient,facility,1,UN,128.3,128.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL TRANSDERM 75 MCG/HR,2500010988,CDM,637,RC,6050570832,NDC,,,,,,inpatient,facility,1,UN,195.72,195.72,15.66,195.72,,,,,,,,,,,,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.15,,,percent of total billed charges,,,,,,,,,195.72,,,percent of total billed charges,,,108.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,195.72,,,percent of total billed charges,,,102.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.66,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.43,,,percent of total billed charges,,
FENTANYL TRANSDERM 75 MCG/HR,2500010988,CDM,637,RC,6050570832,NDC,,,,,,outpatient,facility,1,UN,195.72,195.72,15.66,618.77,,114.3,,,percent of total billed charges,,,38.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,195.72,,,percent of total billed charges,,,172.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,172.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,172.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,71.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,176.15,,,percent of total billed charges,,,,,,,,,195.72,,,percent of total billed charges,,,132.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.31,,,percent of total billed charges,,,,,,,,,,,,,,,105.69,,,percent of total billed charges,,,105.69,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,102.05,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.75,,,percent of total billed charges,,,74.14,,,percent of total billed charges,,,101.36,,,percent of total billed charges,,,,,,,,,,,,,,,39.14,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,72.42,,,percent of total billed charges,,,72.42,,,percent of total billed charges,,,195.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,195.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.66,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,195.72,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,,,,,,,195.72,,,fee schedule,,,182.06,,,percent of total billed charges,,,,,,,,,,,,,,,182.06,,,percent of total billed charges,,,182.06,,,percent of total billed charges,,,182.06,,,percent of total billed charges,,,146.79,,,percent of total billed charges,,,195.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,195.72,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.86,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,137.43,,,percent of total billed charges,,
FENTANYL TRANSDERM 75 MCG/HR,2500010988,CDM,637,RC,6050570832,NDC,999,EAPG,,,,outpatient,facility,1,UN,195.72,195.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FERRIC SUBSULF PASTE 8 ML,2500010997,CDM,250,RC,4878311208,NDC,,,,,,inpatient,facility,8,UN,48.11,48.11,3.85,48.11,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.3,,,percent of total billed charges,,,,,,,,,48.11,,,percent of total billed charges,,,26.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,25.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.78,,,percent of total billed charges,,
FERRIC SUBSULF PASTE 8 ML,2500010997,CDM,250,RC,4878311208,NDC,,,,,,outpatient,facility,8,UN,48.11,48.11,3.85,618.77,,28.1,,,percent of total billed charges,,,9.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,48.11,,,percent of total billed charges,,,42.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,42.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,42.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,43.3,,,percent of total billed charges,,,,,,,,,48.11,,,percent of total billed charges,,,32.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.08,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.56,,,percent of total billed charges,,,18.22,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,9.62,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,48.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,48.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.85,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,,,,,,,48.11,,,fee schedule,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,36.08,,,percent of total billed charges,,,48.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,48.11,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,33.78,,,percent of total billed charges,,
FERRIC SUBSULF PASTE 8 ML,2500010997,CDM,250,RC,4878311208,NDC,999,EAPG,,,,outpatient,facility,8,UN,48.11,48.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FERROUS GLUCONATE 324 MG TAB,2500011023,CDM,637,RC,574050811,NDC,,,,,,inpatient,facility,324,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
FERROUS GLUCONATE 324 MG TAB,2500011023,CDM,637,RC,574050811,NDC,,,,,,outpatient,facility,324,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
FERROUS GLUCONATE 324 MG TAB,2500011023,CDM,637,RC,574050811,NDC,999,EAPG,,,,outpatient,facility,324,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FERROUS SULF 300 MG/5 ML UDC,2500011033,CDM,637,RC,3932815705,NDC,,,,,,inpatient,facility,5,UN,5.54,5.54,0.44,5.54,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.99,,,percent of total billed charges,,,,,,,,,5.54,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,
FERROUS SULF 300 MG/5 ML UDC,2500011033,CDM,637,RC,3932815705,NDC,,,,,,outpatient,facility,5,UN,5.54,5.54,0.44,618.77,,3.24,,,percent of total billed charges,,,1.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.54,,,percent of total billed charges,,,4.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.99,,,percent of total billed charges,,,,,,,,,5.54,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.25,,,percent of total billed charges,,,,,,,,,,,,,,,2.99,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.05,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,5.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.44,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,,,,,,,5.54,,,fee schedule,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,5.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.54,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.89,,,percent of total billed charges,,
FERROUS SULF 300 MG/5 ML UDC,2500011033,CDM,637,RC,3932815705,NDC,999,EAPG,,,,outpatient,facility,5,UN,5.54,5.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FERROUS SULF 325 MG TAB,2500011035,CDM,637,RC,904759161,NDC,,,,,,inpatient,facility,325,UN,1.92,1.92,0.15,1.92,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,,,,,,,1.92,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,
FERROUS SULF 325 MG TAB,2500011035,CDM,637,RC,904759161,NDC,,,,,,outpatient,facility,325,UN,1.92,1.92,0.15,618.77,,1.12,,,percent of total billed charges,,,0.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.92,,,percent of total billed charges,,,1.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.73,,,percent of total billed charges,,,,,,,,,1.92,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.46,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.71,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,1.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,1.92,,,fee schedule,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.79,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.35,,,percent of total billed charges,,
FERROUS SULF 325 MG TAB,2500011035,CDM,637,RC,904759161,NDC,999,EAPG,,,,outpatient,facility,325,UN,1.92,1.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FERROUS SULF 220 MG/5 ML UDC,2500011039,CDM,637,RC,5038377816,NDC,,,,,,inpatient,facility,5,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
FERROUS SULF 220 MG/5 ML UDC,2500011039,CDM,637,RC,5038377816,NDC,,,,,,outpatient,facility,5,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
FERROUS SULF 220 MG/5 ML UDC,2500011039,CDM,637,RC,5038377816,NDC,999,EAPG,,,,outpatient,facility,5,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FINASTERIDE 5 MG TAB,2500011070,CDM,637,RC,904683006,NDC,,,,,,inpatient,facility,5,UN,2.24,2.24,0.18,2.24,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,
FINASTERIDE 5 MG TAB,2500011070,CDM,637,RC,904683006,NDC,,,,,,outpatient,facility,5,UN,2.24,2.24,0.18,618.77,,1.31,,,percent of total billed charges,,,0.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.24,,,percent of total billed charges,,,1.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.02,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,2.24,,,fee schedule,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,2.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.57,,,percent of total billed charges,,
FINASTERIDE 5 MG TAB,2500011070,CDM,637,RC,904683006,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.24,2.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLECAINIDE ACETATE 50 MG TAB,2500011102,CDM,637,RC,5374664101,NDC,,,,,,inpatient,facility,50,UN,8.45,8.45,0.68,8.45,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.6,,,percent of total billed charges,,,,,,,,,8.45,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,4.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.93,,,percent of total billed charges,,
FLECAINIDE ACETATE 50 MG TAB,2500011102,CDM,637,RC,5374664101,NDC,,,,,,outpatient,facility,50,UN,8.45,8.45,0.68,618.77,,4.93,,,percent of total billed charges,,,1.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.45,,,percent of total billed charges,,,7.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.6,,,percent of total billed charges,,,,,,,,,8.45,,,percent of total billed charges,,,5.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.49,,,percent of total billed charges,,,,,,,,,,,,,,,4.56,,,percent of total billed charges,,,4.56,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.41,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.42,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,8.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.68,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,8.45,,,fee schedule,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,8.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.93,,,percent of total billed charges,,
FLECAINIDE ACETATE 50 MG TAB,2500011102,CDM,637,RC,5374664101,NDC,999,EAPG,,,,outpatient,facility,50,UN,8.45,8.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUCONAZOLE 100 MG TAB,2500011130,CDM,637,RC,904650061,NDC,,,,,,inpatient,facility,100,UN,4.68,4.68,0.37,4.68,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.29,,,percent of total billed charges,,
FLUCONAZOLE 100 MG TAB,2500011130,CDM,637,RC,904650061,NDC,,,,,,outpatient,facility,100,UN,4.68,4.68,0.37,618.77,,2.73,,,percent of total billed charges,,,0.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.68,,,percent of total billed charges,,,4.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.21,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.59,,,percent of total billed charges,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,2.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.44,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.73,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,4.68,,,fee schedule,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,4.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.29,,,percent of total billed charges,,
FLUCONAZOLE 100 MG TAB,2500011130,CDM,637,RC,904650061,NDC,999,EAPG,,,,outpatient,facility,100,UN,4.68,4.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUCONAZOLE 150 MG TAB,2500011135,CDM,637,RC,5723700511,NDC,,,,,,inpatient,facility,150,UN,45.97,45.97,3.68,45.97,,,,,,,,,,,,,,45.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.37,,,percent of total billed charges,,,,,,,,,45.97,,,percent of total billed charges,,,25.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.97,,,percent of total billed charges,,,,,,,,,,,,,,,45.97,,,percent of total billed charges,,,23.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,45.97,,,percent of total billed charges,,,45.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,45.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.28,,,percent of total billed charges,,
FLUCONAZOLE 150 MG TAB,2500011135,CDM,637,RC,5723700511,NDC,,,,,,outpatient,facility,150,UN,45.97,45.97,3.68,618.77,,26.85,,,percent of total billed charges,,,8.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,45.97,,,percent of total billed charges,,,40.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,40.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,40.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,45.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,41.37,,,percent of total billed charges,,,,,,,,,45.97,,,percent of total billed charges,,,31.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.3,,,percent of total billed charges,,,,,,,,,,,,,,,24.82,,,percent of total billed charges,,,24.82,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,45.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.97,,,percent of total billed charges,,,45.97,,,percent of total billed charges,,,45.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.94,,,percent of total billed charges,,,17.41,,,percent of total billed charges,,,23.81,,,percent of total billed charges,,,,,,,,,,,,,,,9.19,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,17.01,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,45.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,45.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.68,,,percent of total billed charges,,,45.97,,,percent of total billed charges,,,45.97,,,percent of total billed charges,,,,,,,,,,,,,,,45.97,,,percent of total billed charges,,,45.97,,,percent of total billed charges,,,,,,,,,45.97,,,fee schedule,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,34.48,,,percent of total billed charges,,,45.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,45.97,,,percent of total billed charges,,,45.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,32.28,,,percent of total billed charges,,
FLUCONAZOLE 150 MG TAB,2500011135,CDM,637,RC,5723700511,NDC,999,EAPG,,,,outpatient,facility,150,UN,45.97,45.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUDROCORTISONE 0.1 MG TAB,2500011150,CDM,637,RC,5026833015,NDC,,,,,,inpatient,facility,0.1,UN,5.28,5.28,0.42,5.28,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,5.28,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.71,,,percent of total billed charges,,
FLUDROCORTISONE 0.1 MG TAB,2500011150,CDM,637,RC,5026833015,NDC,,,,,,outpatient,facility,0.1,UN,5.28,5.28,0.42,618.77,,3.08,,,percent of total billed charges,,,1.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.28,,,percent of total billed charges,,,4.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.75,,,percent of total billed charges,,,,,,,,,5.28,,,percent of total billed charges,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,5.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.42,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,5.28,,,fee schedule,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,5.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.71,,,percent of total billed charges,,
FLUDROCORTISONE 0.1 MG TAB,2500011150,CDM,637,RC,5026833015,NDC,999,EAPG,,,,outpatient,facility,0.1,UN,5.28,5.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUMAZENIL 0.1 MG/ML 5 ML INJ,2500011160,CDM,250,RC,J3490,HCPCS,3600014810,NDC,,,,inpatient,facility,5,UN,23.39,23.39,1.87,23.39,,,,,,,,,,,,,,23.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.05,,,percent of total billed charges,,,,,,,,,23.39,,,percent of total billed charges,,,12.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.39,,,percent of total billed charges,,,,,,,,,,,,,,,23.39,,,percent of total billed charges,,,12.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,23.39,,,percent of total billed charges,,,23.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.42,,,percent of total billed charges,,
FLUMAZENIL 0.1 MG/ML 5 ML INJ,2500011160,CDM,250,RC,J3490,HCPCS,3600014810,NDC,,,,outpatient,facility,5,UN,23.39,23.39,1.2,618.77,,13.66,,,percent of total billed charges,,,4.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,23.39,,,percent of total billed charges,,,20.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,20.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,20.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,21.05,,,percent of total billed charges,,,,,,,,,23.39,,,percent of total billed charges,,,15.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.96,,,percent of total billed charges,,,,,,,,,,,,,,,23.39,,,percent of total billed charges,,,23.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,23.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.2,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.78,,,percent of total billed charges,,,8.86,,,percent of total billed charges,,,12.11,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,23.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.87,,,percent of total billed charges,,,23.39,,,percent of total billed charges,,,23.39,,,percent of total billed charges,,,,,,,,,,,,,,,23.39,,,percent of total billed charges,,,23.39,,,percent of total billed charges,,,,,,,,,23.39,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,17.54,,,percent of total billed charges,,,23.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,23.39,,,percent of total billed charges,,,23.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,16.42,,,percent of total billed charges,,
FLUMAZENIL 0.1 MG/ML 5 ML INJ,2500011160,CDM,250,RC,J3490,HCPCS,3600014810,NDC,435,EAPG,,outpatient,facility,5,UN,23.39,23.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUOCINONIDE 0.05  CR 15 GM,2500011210,CDM,637,RC,5167212791,NDC,,,,,,inpatient,facility,15,UN,150.32,150.32,12.03,150.32,,,,,,,,,,,,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.29,,,percent of total billed charges,,,,,,,,,150.32,,,percent of total billed charges,,,83.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,150.32,,,percent of total billed charges,,,78.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.03,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.55,,,percent of total billed charges,,
FLUOCINONIDE 0.05  CR 15 GM,2500011210,CDM,637,RC,5167212791,NDC,,,,,,outpatient,facility,15,UN,150.32,150.32,12.03,618.77,,87.79,,,percent of total billed charges,,,29.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,150.32,,,percent of total billed charges,,,132.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,132.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,132.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,55.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,135.29,,,percent of total billed charges,,,,,,,,,150.32,,,percent of total billed charges,,,101.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.45,,,percent of total billed charges,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,,81.17,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.38,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.24,,,percent of total billed charges,,,56.94,,,percent of total billed charges,,,77.85,,,percent of total billed charges,,,,,,,,,,,,,,,30.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,55.62,,,percent of total billed charges,,,55.62,,,percent of total billed charges,,,150.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,150.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.03,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,150.32,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,,,,,,,150.32,,,fee schedule,,,139.83,,,percent of total billed charges,,,,,,,,,,,,,,,139.83,,,percent of total billed charges,,,139.83,,,percent of total billed charges,,,139.83,,,percent of total billed charges,,,112.74,,,percent of total billed charges,,,150.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,150.32,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,105.55,,,percent of total billed charges,,
FLUOCINONIDE 0.05  CR 15 GM,2500011210,CDM,637,RC,5167212791,NDC,999,EAPG,,,,outpatient,facility,15,UN,150.32,150.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUOCINONIDE 0.05  OINT 30 GM,2500011216,CDM,637,RC,5167212642,NDC,,,,,,inpatient,facility,30,UN,466.95,466.95,37.36,466.95,,,,,,,,,,,,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.25,,,percent of total billed charges,,,,,,,,,466.95,,,percent of total billed charges,,,258.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,426.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,466.95,,,percent of total billed charges,,,243.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.36,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,327.89,,,percent of total billed charges,,
FLUOCINONIDE 0.05  OINT 30 GM,2500011216,CDM,637,RC,5167212642,NDC,,,,,,outpatient,facility,30,UN,466.95,466.95,37.36,618.77,,272.7,,,percent of total billed charges,,,91.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,466.95,,,percent of total billed charges,,,411.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,411.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,411.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,170.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,420.25,,,percent of total billed charges,,,,,,,,,466.95,,,percent of total billed charges,,,316.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.62,,,percent of total billed charges,,,,,,,,,,,,,,,252.15,,,percent of total billed charges,,,252.15,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,243.47,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.88,,,percent of total billed charges,,,176.88,,,percent of total billed charges,,,241.83,,,percent of total billed charges,,,,,,,,,,,,,,,93.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,172.77,,,percent of total billed charges,,,172.77,,,percent of total billed charges,,,466.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,466.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,37.36,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,466.95,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,,,,,,,466.95,,,fee schedule,,,434.36,,,percent of total billed charges,,,,,,,,,,,,,,,434.36,,,percent of total billed charges,,,434.36,,,percent of total billed charges,,,434.36,,,percent of total billed charges,,,350.21,,,percent of total billed charges,,,466.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,466.95,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,327.89,,,percent of total billed charges,,
FLUOCINONIDE 0.05  OINT 30 GM,2500011216,CDM,637,RC,5167212642,NDC,999,EAPG,,,,outpatient,facility,30,UN,466.95,466.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUORESCEIN SOD OPH 1 MG STRP,2500011226,CDM,637,RC,1723890030,NDC,,,,,,inpatient,facility,1,UN,0.69,0.69,0.06,0.69,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,
FLUORESCEIN SOD OPH 1 MG STRP,2500011226,CDM,637,RC,1723890030,NDC,,,,,,outpatient,facility,1,UN,0.69,0.69,0.06,618.77,,0.4,,,percent of total billed charges,,,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.69,,,percent of total billed charges,,,0.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.62,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.69,,,fee schedule,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.48,,,percent of total billed charges,,
FLUORESCEIN SOD OPH 1 MG STRP,2500011226,CDM,637,RC,1723890030,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.69,0.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUOXETINE HCL 10 MG CAP,2500011272,CDM,637,RC,904578461,NDC,,,,,,inpatient,facility,10,UN,0.29,0.29,0.02,0.29,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,
FLUOXETINE HCL 10 MG CAP,2500011272,CDM,637,RC,904578461,NDC,,,,,,outpatient,facility,10,UN,0.29,0.29,0.02,618.77,,0.17,,,percent of total billed charges,,,0.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.29,,,percent of total billed charges,,,0.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.26,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.11,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,fee schedule,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.2,,,percent of total billed charges,,
FLUOXETINE HCL 10 MG CAP,2500011272,CDM,637,RC,904578461,NDC,999,EAPG,,,,outpatient,facility,10,UN,0.29,0.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUOXETINE HCL 20 MG CAP,2500011274,CDM,637,RC,904578561,NDC,,,,,,inpatient,facility,20,UN,0.29,0.29,0.02,0.29,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,
FLUOXETINE HCL 20 MG CAP,2500011274,CDM,637,RC,904578561,NDC,,,,,,outpatient,facility,20,UN,0.29,0.29,0.02,618.77,,0.17,,,percent of total billed charges,,,0.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.29,,,percent of total billed charges,,,0.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.26,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.11,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,fee schedule,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.2,,,percent of total billed charges,,
FLUOXETINE HCL 20 MG CAP,2500011274,CDM,637,RC,904578561,NDC,999,EAPG,,,,outpatient,facility,20,UN,0.29,0.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUOXETINE HCL 20 MG/5 ML UDC,2500011277,CDM,637,RC,6068724477,NDC,,,,,,inpatient,facility,5,UN,23.27,23.27,1.86,23.27,,,,,,,,,,,,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.94,,,percent of total billed charges,,,,,,,,,23.27,,,percent of total billed charges,,,12.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,23.27,,,percent of total billed charges,,,12.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.34,,,percent of total billed charges,,
FLUOXETINE HCL 20 MG/5 ML UDC,2500011277,CDM,637,RC,6068724477,NDC,,,,,,outpatient,facility,5,UN,23.27,23.27,1.86,618.77,,13.59,,,percent of total billed charges,,,4.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,23.27,,,percent of total billed charges,,,20.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,20.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,20.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,20.94,,,percent of total billed charges,,,,,,,,,23.27,,,percent of total billed charges,,,15.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.87,,,percent of total billed charges,,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.13,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.69,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,12.05,,,percent of total billed charges,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,23.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.86,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,23.27,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,,,,,,,23.27,,,fee schedule,,,21.65,,,percent of total billed charges,,,,,,,,,,,,,,,21.65,,,percent of total billed charges,,,21.65,,,percent of total billed charges,,,21.65,,,percent of total billed charges,,,17.45,,,percent of total billed charges,,,23.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,23.27,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,16.34,,,percent of total billed charges,,
FLUOXETINE HCL 20 MG/5 ML UDC,2500011277,CDM,637,RC,6068724477,NDC,999,EAPG,,,,outpatient,facility,5,UN,23.27,23.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUPHENAZINE 1 MG TAB,2500011300,CDM,637,RC,527178801,NDC,,,,,,inpatient,facility,1,UN,14.49,14.49,1.16,14.49,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,,,,,,,14.49,,,percent of total billed charges,,,8.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.17,,,percent of total billed charges,,
FLUPHENAZINE 1 MG TAB,2500011300,CDM,637,RC,527178801,NDC,,,,,,outpatient,facility,1,UN,14.49,14.49,1.16,618.77,,8.46,,,percent of total billed charges,,,2.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.49,,,percent of total billed charges,,,12.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.04,,,percent of total billed charges,,,,,,,,,14.49,,,percent of total billed charges,,,9.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.13,,,percent of total billed charges,,,,,,,,,,,,,,,7.82,,,percent of total billed charges,,,7.82,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.01,,,percent of total billed charges,,,5.49,,,percent of total billed charges,,,7.5,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.36,,,percent of total billed charges,,,5.36,,,percent of total billed charges,,,14.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.16,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,14.49,,,fee schedule,,,13.48,,,percent of total billed charges,,,,,,,,,,,,,,,13.48,,,percent of total billed charges,,,13.48,,,percent of total billed charges,,,13.48,,,percent of total billed charges,,,10.87,,,percent of total billed charges,,,14.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.17,,,percent of total billed charges,,
FLUPHENAZINE 1 MG TAB,2500011300,CDM,637,RC,527178801,NDC,999,EAPG,,,,outpatient,facility,1,UN,14.49,14.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUPHENAZINE 5 MG TAB,2500011305,CDM,637,RC,527179001,NDC,,,,,,inpatient,facility,5,UN,30.36,30.36,2.43,30.36,,,,,,,,,,,,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.32,,,percent of total billed charges,,,,,,,,,30.36,,,percent of total billed charges,,,16.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,30.36,,,percent of total billed charges,,,15.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.32,,,percent of total billed charges,,
FLUPHENAZINE 5 MG TAB,2500011305,CDM,637,RC,527179001,NDC,,,,,,outpatient,facility,5,UN,30.36,30.36,2.43,618.77,,17.73,,,percent of total billed charges,,,5.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,30.36,,,percent of total billed charges,,,26.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,26.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,26.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,27.32,,,percent of total billed charges,,,,,,,,,30.36,,,percent of total billed charges,,,20.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.32,,,percent of total billed charges,,,,,,,,,,,,,,,16.39,,,percent of total billed charges,,,16.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.83,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,11.5,,,percent of total billed charges,,,15.72,,,percent of total billed charges,,,,,,,,,,,,,,,6.07,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,11.23,,,percent of total billed charges,,,11.23,,,percent of total billed charges,,,30.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.43,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,30.36,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,30.36,,,fee schedule,,,28.24,,,percent of total billed charges,,,,,,,,,,,,,,,28.24,,,percent of total billed charges,,,28.24,,,percent of total billed charges,,,28.24,,,percent of total billed charges,,,22.77,,,percent of total billed charges,,,30.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,30.36,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,21.32,,,percent of total billed charges,,
FLUPHENAZINE 5 MG TAB,2500011305,CDM,637,RC,527179001,NDC,999,EAPG,,,,outpatient,facility,5,UN,30.36,30.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUTICASONE 0.05  NASAL 16 GM,2500011350,CDM,637,RC,6050508291,NDC,,,,,,inpatient,facility,16,UN,69.35,69.35,5.55,69.35,,,,,,,,,,,,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.41,,,percent of total billed charges,,,,,,,,,69.35,,,percent of total billed charges,,,38.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,69.35,,,percent of total billed charges,,,36.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.55,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.7,,,percent of total billed charges,,
FLUTICASONE 0.05  NASAL 16 GM,2500011350,CDM,637,RC,6050508291,NDC,,,,,,outpatient,facility,16,UN,69.35,69.35,5.55,618.77,,40.5,,,percent of total billed charges,,,13.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,69.35,,,percent of total billed charges,,,61.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,61.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,61.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,25.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,62.41,,,percent of total billed charges,,,,,,,,,69.35,,,percent of total billed charges,,,46.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,37.45,,,percent of total billed charges,,,37.45,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.16,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.71,,,percent of total billed charges,,,26.27,,,percent of total billed charges,,,35.92,,,percent of total billed charges,,,,,,,,,,,,,,,13.87,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,25.66,,,percent of total billed charges,,,25.66,,,percent of total billed charges,,,69.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,69.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.55,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,69.35,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,69.35,,,fee schedule,,,64.51,,,percent of total billed charges,,,,,,,,,,,,,,,64.51,,,percent of total billed charges,,,64.51,,,percent of total billed charges,,,64.51,,,percent of total billed charges,,,52.01,,,percent of total billed charges,,,69.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,69.35,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.67,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,48.7,,,percent of total billed charges,,
FLUTICASONE 0.05  NASAL 16 GM,2500011350,CDM,637,RC,6050508291,NDC,999,EAPG,,,,outpatient,facility,16,UN,69.35,69.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUVOXAMINE MAL 100 MG TAB,2500011380,CDM,637,RC,6255916001,NDC,,,,,,inpatient,facility,100,UN,8.68,8.68,0.69,8.68,,,,,,,,,,,,,,8.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.81,,,percent of total billed charges,,,,,,,,,8.68,,,percent of total billed charges,,,4.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.68,,,percent of total billed charges,,,,,,,,,,,,,,,8.68,,,percent of total billed charges,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,8.68,,,percent of total billed charges,,,8.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.1,,,percent of total billed charges,,
FLUVOXAMINE MAL 100 MG TAB,2500011380,CDM,637,RC,6255916001,NDC,,,,,,outpatient,facility,100,UN,8.68,8.68,0.69,618.77,,5.07,,,percent of total billed charges,,,1.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.68,,,percent of total billed charges,,,7.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.81,,,percent of total billed charges,,,,,,,,,8.68,,,percent of total billed charges,,,5.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.67,,,percent of total billed charges,,,,,,,,,,,,,,,4.69,,,percent of total billed charges,,,4.69,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,8.68,,,percent of total billed charges,,,8.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,3.29,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.21,,,percent of total billed charges,,,3.21,,,percent of total billed charges,,,8.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.69,,,percent of total billed charges,,,8.68,,,percent of total billed charges,,,8.68,,,percent of total billed charges,,,,,,,,,,,,,,,8.68,,,percent of total billed charges,,,8.68,,,percent of total billed charges,,,,,,,,,8.68,,,fee schedule,,,8.07,,,percent of total billed charges,,,,,,,,,,,,,,,8.07,,,percent of total billed charges,,,8.07,,,percent of total billed charges,,,8.07,,,percent of total billed charges,,,6.51,,,percent of total billed charges,,,8.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.68,,,percent of total billed charges,,,8.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.1,,,percent of total billed charges,,
FLUVOXAMINE MAL 100 MG TAB,2500011380,CDM,637,RC,6255916001,NDC,999,EAPG,,,,outpatient,facility,100,UN,8.68,8.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUVOXAMINE MAL 50 MG TAB,2500011385,CDM,637,RC,6255915901,NDC,,,,,,inpatient,facility,50,UN,8.48,8.48,0.68,8.48,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.63,,,percent of total billed charges,,,,,,,,,8.48,,,percent of total billed charges,,,4.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.95,,,percent of total billed charges,,
FLUVOXAMINE MAL 50 MG TAB,2500011385,CDM,637,RC,6255915901,NDC,,,,,,outpatient,facility,50,UN,8.48,8.48,0.68,618.77,,4.95,,,percent of total billed charges,,,1.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.48,,,percent of total billed charges,,,7.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.63,,,percent of total billed charges,,,,,,,,,8.48,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.51,,,percent of total billed charges,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.44,,,percent of total billed charges,,,3.21,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.14,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,8.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.68,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,8.48,,,fee schedule,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,6.36,,,percent of total billed charges,,,8.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.48,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.95,,,percent of total billed charges,,
FLUVOXAMINE MAL 50 MG TAB,2500011385,CDM,637,RC,6255915901,NDC,999,EAPG,,,,outpatient,facility,50,UN,8.48,8.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FOLIC ACID 1 MG TAB,2500011391,CDM,637,RC,6258489701,NDC,,,,,,inpatient,facility,1,UN,0.62,0.62,0.05,0.62,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,
FOLIC ACID 1 MG TAB,2500011391,CDM,637,RC,6258489701,NDC,,,,,,outpatient,facility,1,UN,0.62,0.62,0.05,618.77,,0.36,,,percent of total billed charges,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.62,,,percent of total billed charges,,,0.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.56,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,0.62,,,fee schedule,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.44,,,percent of total billed charges,,
FOLIC ACID 1 MG TAB,2500011391,CDM,637,RC,6258489701,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.62,0.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FOLIC ACID 5 MG/ML INJ,2500011394,CDM,250,RC,J3490,HCPCS,6332318410,NDC,,,,inpatient,facility,1,UN,18.51,18.51,1.48,18.51,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.66,,,percent of total billed charges,,,,,,,,,18.51,,,percent of total billed charges,,,10.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,9.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13,,,percent of total billed charges,,
FOLIC ACID 5 MG/ML INJ,2500011394,CDM,250,RC,J3490,HCPCS,6332318410,NDC,,,,outpatient,facility,1,UN,18.51,18.51,1.2,618.77,,10.81,,,percent of total billed charges,,,3.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,18.51,,,percent of total billed charges,,,16.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,16.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,16.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,16.66,,,percent of total billed charges,,,,,,,,,18.51,,,percent of total billed charges,,,12.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.65,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.07,,,percent of total billed charges,,,7.01,,,percent of total billed charges,,,9.59,,,percent of total billed charges,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,18.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.48,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,,,,,,,18.51,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,13.88,,,percent of total billed charges,,,18.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,18.51,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.26,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,13,,,percent of total billed charges,,
FOLIC ACID 5 MG/ML INJ,2500011394,CDM,250,RC,J3490,HCPCS,6332318410,NDC,435,EAPG,,outpatient,facility,1,UN,18.51,18.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FOSFOMYCIN TROMETHAM 3 GM PK,2500011400,CDM,637,RC,7070026894,NDC,,,,,,inpatient,facility,3,UN,331.32,331.32,26.51,331.32,,,,,,,,,,,,,,331.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.19,,,percent of total billed charges,,,,,,,,,331.32,,,percent of total billed charges,,,183.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.32,,,percent of total billed charges,,,,,,,,,,,,,,,331.32,,,percent of total billed charges,,,172.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.51,,,percent of total billed charges,,,331.32,,,percent of total billed charges,,,331.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,331.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.65,,,percent of total billed charges,,
FOSFOMYCIN TROMETHAM 3 GM PK,2500011400,CDM,637,RC,7070026894,NDC,,,,,,outpatient,facility,3,UN,331.32,331.32,26.51,618.77,,193.49,,,percent of total billed charges,,,64.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,331.32,,,percent of total billed charges,,,291.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,291.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,291.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,331.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,121.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,298.19,,,percent of total billed charges,,,,,,,,,331.32,,,percent of total billed charges,,,224.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.45,,,percent of total billed charges,,,,,,,,,,,,,,,178.91,,,percent of total billed charges,,,178.91,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,331.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,172.75,,,percent of total billed charges,,,331.32,,,percent of total billed charges,,,331.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.8,,,percent of total billed charges,,,125.5,,,percent of total billed charges,,,171.59,,,percent of total billed charges,,,,,,,,,,,,,,,66.26,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,122.59,,,percent of total billed charges,,,122.59,,,percent of total billed charges,,,331.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,331.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.51,,,percent of total billed charges,,,331.32,,,percent of total billed charges,,,331.32,,,percent of total billed charges,,,,,,,,,,,,,,,331.32,,,percent of total billed charges,,,331.32,,,percent of total billed charges,,,,,,,,,331.32,,,fee schedule,,,308.19,,,percent of total billed charges,,,,,,,,,,,,,,,308.19,,,percent of total billed charges,,,308.19,,,percent of total billed charges,,,308.19,,,percent of total billed charges,,,248.49,,,percent of total billed charges,,,331.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,331.32,,,percent of total billed charges,,,331.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,232.65,,,percent of total billed charges,,
FOSFOMYCIN TROMETHAM 3 GM PK,2500011400,CDM,637,RC,7070026894,NDC,999,EAPG,,,,outpatient,facility,3,UN,331.32,331.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FUROSEMIDE 20 MG TAB,2500011430,CDM,637,RC,5107907220,NDC,,,,,,inpatient,facility,20,UN,0.49,0.49,0.04,0.49,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,
FUROSEMIDE 20 MG TAB,2500011430,CDM,637,RC,5107907220,NDC,,,,,,outpatient,facility,20,UN,0.49,0.49,0.04,618.77,,0.29,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.49,,,percent of total billed charges,,,0.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.44,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.18,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,0.49,,,fee schedule,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,0.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.34,,,percent of total billed charges,,
FUROSEMIDE 20 MG TAB,2500011430,CDM,637,RC,5107907220,NDC,999,EAPG,,,,outpatient,facility,20,UN,0.49,0.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FUROSEMIDE 40 MG TAB,2500011431,CDM,637,RC,5107907320,NDC,,,,,,inpatient,facility,40,UN,0.56,0.56,0.04,0.56,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,
FUROSEMIDE 40 MG TAB,2500011431,CDM,637,RC,5107907320,NDC,,,,,,outpatient,facility,40,UN,0.56,0.56,0.04,618.77,,0.33,,,percent of total billed charges,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.5,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.56,,,fee schedule,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,0.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.39,,,percent of total billed charges,,
FUROSEMIDE 40 MG TAB,2500011431,CDM,637,RC,5107907320,NDC,999,EAPG,,,,outpatient,facility,40,UN,0.56,0.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FUROSEMIDE SOLN 40 MG/4 ML,2500011437,CDM,637,RC,6809475662,NDC,,,,,,inpatient,facility,4,UN,8.12,8.12,0.65,8.12,,,,,,,,,,,,,,8.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.31,,,percent of total billed charges,,,,,,,,,8.12,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.12,,,percent of total billed charges,,,,,,,,,,,,,,,8.12,,,percent of total billed charges,,,4.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,8.12,,,percent of total billed charges,,,8.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,
FUROSEMIDE SOLN 40 MG/4 ML,2500011437,CDM,637,RC,6809475662,NDC,,,,,,outpatient,facility,4,UN,8.12,8.12,0.65,618.77,,4.74,,,percent of total billed charges,,,1.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.12,,,percent of total billed charges,,,7.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.31,,,percent of total billed charges,,,,,,,,,8.12,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.24,,,percent of total billed charges,,,,,,,,,,,,,,,4.38,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.23,,,percent of total billed charges,,,8.12,,,percent of total billed charges,,,8.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.17,,,percent of total billed charges,,,3.08,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,8.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.65,,,percent of total billed charges,,,8.12,,,percent of total billed charges,,,8.12,,,percent of total billed charges,,,,,,,,,,,,,,,8.12,,,percent of total billed charges,,,8.12,,,percent of total billed charges,,,,,,,,,8.12,,,fee schedule,,,7.55,,,percent of total billed charges,,,,,,,,,,,,,,,7.55,,,percent of total billed charges,,,7.55,,,percent of total billed charges,,,7.55,,,percent of total billed charges,,,6.09,,,percent of total billed charges,,,8.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.12,,,percent of total billed charges,,,8.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.7,,,percent of total billed charges,,
FUROSEMIDE SOLN 40 MG/4 ML,2500011437,CDM,637,RC,6809475662,NDC,999,EAPG,,,,outpatient,facility,4,UN,8.12,8.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GABAPENTIN 100 MG CAP,2500011440,CDM,637,RC,6373959110,NDC,,,,,,inpatient,facility,100,UN,0.29,0.29,0.02,0.29,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,
GABAPENTIN 100 MG CAP,2500011440,CDM,637,RC,6373959110,NDC,,,,,,outpatient,facility,100,UN,0.29,0.29,0.02,618.77,,0.17,,,percent of total billed charges,,,0.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.29,,,percent of total billed charges,,,0.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.26,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.11,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,fee schedule,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.2,,,percent of total billed charges,,
GABAPENTIN 100 MG CAP,2500011440,CDM,637,RC,6373959110,NDC,999,EAPG,,,,outpatient,facility,100,UN,0.29,0.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GABAPENTIN 300 MG CAP,2500011443,CDM,637,RC,6787722301,NDC,,,,,,inpatient,facility,300,UN,4.42,4.42,0.35,4.42,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.98,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,
GABAPENTIN 300 MG CAP,2500011443,CDM,637,RC,6787722301,NDC,,,,,,outpatient,facility,300,UN,4.42,4.42,0.35,618.77,,2.58,,,percent of total billed charges,,,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.42,,,percent of total billed charges,,,3.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.98,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.64,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,4.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.35,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,4.42,,,fee schedule,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,4.11,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,4.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.1,,,percent of total billed charges,,
GABAPENTIN 300 MG CAP,2500011443,CDM,637,RC,6787722301,NDC,999,EAPG,,,,outpatient,facility,300,UN,4.42,4.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GABAPENTIN 400 MG CAP,2500011444,CDM,637,RC,904666761,NDC,,,,,,inpatient,facility,400,UN,0.69,0.69,0.06,0.69,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,
GABAPENTIN 400 MG CAP,2500011444,CDM,637,RC,904666761,NDC,,,,,,outpatient,facility,400,UN,0.69,0.69,0.06,618.77,,0.4,,,percent of total billed charges,,,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.69,,,percent of total billed charges,,,0.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.62,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.69,,,fee schedule,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.48,,,percent of total billed charges,,
GABAPENTIN 400 MG CAP,2500011444,CDM,637,RC,904666761,NDC,999,EAPG,,,,outpatient,facility,400,UN,0.69,0.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GABAPENTIN 250 MG  5 ML,2500011448,CDM,637,RC,5038331107,NDC,,,,,,inpatient,facility,5,UN,6.86,6.86,0.55,6.86,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.17,,,percent of total billed charges,,,,,,,,,6.86,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.82,,,percent of total billed charges,,
GABAPENTIN 250 MG  5 ML,2500011448,CDM,637,RC,5038331107,NDC,,,,,,outpatient,facility,5,UN,6.86,6.86,0.55,618.77,,4.01,,,percent of total billed charges,,,1.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.86,,,percent of total billed charges,,,6.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.17,,,percent of total billed charges,,,,,,,,,6.86,,,percent of total billed charges,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,3.7,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,3.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,6.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.55,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,6.86,,,fee schedule,,,6.38,,,percent of total billed charges,,,,,,,,,,,,,,,6.38,,,percent of total billed charges,,,6.38,,,percent of total billed charges,,,6.38,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,6.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.82,,,percent of total billed charges,,
GABAPENTIN 250 MG  5 ML,2500011448,CDM,637,RC,5038331107,NDC,999,EAPG,,,,outpatient,facility,5,UN,6.86,6.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GASTROGRAFIN 30 ML UD,2500011460,CDM,636,RC,Q9963,HCPCS,270044535,NDC,,,,inpatient,facility,30,UN,77.68,77.68,6.21,77.68,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.91,,,percent of total billed charges,,,,,,,,,77.68,,,percent of total billed charges,,,43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,40.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.21,,,percent of total billed charges,,,77.68,,,percent of total billed charges,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.55,,,percent of total billed charges,,
GASTROGRAFIN 30 ML UD,2500011460,CDM,636,RC,Q9963,HCPCS,270044535,NDC,,,,outpatient,facility,30,UN,77.68,77.68,0.22,618.77,,45.37,,,percent of total billed charges,,,15.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,77.68,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,28.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,69.91,,,percent of total billed charges,,,,,,,,,77.68,,,percent of total billed charges,,,52.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.5,,,percent of total billed charges,,,77.68,,,percent of total billed charges,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.04,,,percent of total billed charges,,,29.43,,,percent of total billed charges,,,40.23,,,percent of total billed charges,,,,,,,,,,,,,,,15.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,77.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,77.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.21,,,percent of total billed charges,,,77.68,,,percent of total billed charges,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,77.68,,,percent of total billed charges,,,,,,,,,77.68,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.22,,,fee schedule,,,77.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,77.68,,,percent of total billed charges,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,54.55,,,percent of total billed charges,,
GASTROGRAFIN 30 ML UD,2500011460,CDM,636,RC,Q9963,HCPCS,270044535,NDC,999,EAPG,,outpatient,facility,30,UN,77.68,77.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GEMFIBROZIL 600 MG TAB,2500011500,CDM,637,RC,6068722401,NDC,,,,,,inpatient,facility,600,UN,7.66,7.66,0.61,7.66,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.89,,,percent of total billed charges,,,,,,,,,7.66,,,percent of total billed charges,,,4.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,
GEMFIBROZIL 600 MG TAB,2500011500,CDM,637,RC,6068722401,NDC,,,,,,outpatient,facility,600,UN,7.66,7.66,0.61,618.77,,4.47,,,percent of total billed charges,,,1.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.66,,,percent of total billed charges,,,6.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.89,,,percent of total billed charges,,,,,,,,,7.66,,,percent of total billed charges,,,5.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.88,,,percent of total billed charges,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,,4.14,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.82,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,3.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.83,,,percent of total billed charges,,,2.83,,,percent of total billed charges,,,7.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.61,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,7.66,,,fee schedule,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,5.75,,,percent of total billed charges,,,7.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.66,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.38,,,percent of total billed charges,,
GEMFIBROZIL 600 MG TAB,2500011500,CDM,637,RC,6068722401,NDC,999,EAPG,,,,outpatient,facility,600,UN,7.66,7.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENTAMICIN 0.1  CR 15 GM,2500011521,CDM,637,RC,713068315,NDC,,,,,,inpatient,facility,15,UN,162.95,162.95,13.04,162.95,,,,,,,,,,,,,,162.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.66,,,percent of total billed charges,,,,,,,,,162.95,,,percent of total billed charges,,,90.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.95,,,percent of total billed charges,,,,,,,,,,,,,,,162.95,,,percent of total billed charges,,,84.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,162.95,,,percent of total billed charges,,,162.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,162.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.42,,,percent of total billed charges,,
GENTAMICIN 0.1  CR 15 GM,2500011521,CDM,637,RC,713068315,NDC,,,,,,outpatient,facility,15,UN,162.95,162.95,13.04,618.77,,95.16,,,percent of total billed charges,,,31.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,162.95,,,percent of total billed charges,,,143.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,143.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,143.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,162.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,59.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,146.66,,,percent of total billed charges,,,,,,,,,162.95,,,percent of total billed charges,,,110.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.15,,,percent of total billed charges,,,,,,,,,,,,,,,87.99,,,percent of total billed charges,,,87.99,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,162.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,84.96,,,percent of total billed charges,,,162.95,,,percent of total billed charges,,,162.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.84,,,percent of total billed charges,,,61.73,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,,,,,,,,,,,,,32.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,60.29,,,percent of total billed charges,,,60.29,,,percent of total billed charges,,,162.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,162.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.04,,,percent of total billed charges,,,162.95,,,percent of total billed charges,,,162.95,,,percent of total billed charges,,,,,,,,,,,,,,,162.95,,,percent of total billed charges,,,162.95,,,percent of total billed charges,,,,,,,,,162.95,,,fee schedule,,,151.58,,,percent of total billed charges,,,,,,,,,,,,,,,151.58,,,percent of total billed charges,,,151.58,,,percent of total billed charges,,,151.58,,,percent of total billed charges,,,122.21,,,percent of total billed charges,,,162.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,162.95,,,percent of total billed charges,,,162.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,114.42,,,percent of total billed charges,,
GENTAMICIN 0.1  CR 15 GM,2500011521,CDM,637,RC,713068315,NDC,999,EAPG,,,,outpatient,facility,15,UN,162.95,162.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENTAMICIN 0.3  OP OINT 3.5 GM,2500011525,CDM,637,RC,1747828435,NDC,,,,,,inpatient,facility,3.5,UN,128.54,128.54,10.28,128.54,,,,,,,,,,,,,,128.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.69,,,percent of total billed charges,,,,,,,,,128.54,,,percent of total billed charges,,,71.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.54,,,percent of total billed charges,,,,,,,,,,,,,,,128.54,,,percent of total billed charges,,,67.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.28,,,percent of total billed charges,,,128.54,,,percent of total billed charges,,,128.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,128.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.26,,,percent of total billed charges,,
GENTAMICIN 0.3  OP OINT 3.5 GM,2500011525,CDM,637,RC,1747828435,NDC,,,,,,outpatient,facility,3.5,UN,128.54,128.54,10.28,618.77,,75.07,,,percent of total billed charges,,,25.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,128.54,,,percent of total billed charges,,,113.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,113.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,113.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,128.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,47.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,115.69,,,percent of total billed charges,,,,,,,,,128.54,,,percent of total billed charges,,,87.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.72,,,percent of total billed charges,,,,,,,,,,,,,,,69.41,,,percent of total billed charges,,,69.41,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,128.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.02,,,percent of total billed charges,,,128.54,,,percent of total billed charges,,,128.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.69,,,percent of total billed charges,,,48.69,,,percent of total billed charges,,,66.57,,,percent of total billed charges,,,,,,,,,,,,,,,25.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,47.56,,,percent of total billed charges,,,47.56,,,percent of total billed charges,,,128.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,128.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.28,,,percent of total billed charges,,,128.54,,,percent of total billed charges,,,128.54,,,percent of total billed charges,,,,,,,,,,,,,,,128.54,,,percent of total billed charges,,,128.54,,,percent of total billed charges,,,,,,,,,128.54,,,fee schedule,,,119.57,,,percent of total billed charges,,,,,,,,,,,,,,,119.57,,,percent of total billed charges,,,119.57,,,percent of total billed charges,,,119.57,,,percent of total billed charges,,,96.41,,,percent of total billed charges,,,128.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,128.54,,,percent of total billed charges,,,128.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,90.26,,,percent of total billed charges,,
GENTAMICIN 0.3  OP OINT 3.5 GM,2500011525,CDM,637,RC,1747828435,NDC,999,EAPG,,,,outpatient,facility,3.5,UN,128.54,128.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENTAMICIN 0.3  OP SOLN 5 ML,2500011526,CDM,637,RC,6131463305,NDC,,,,,,inpatient,facility,5,UN,71.61,71.61,5.73,71.61,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.45,,,percent of total billed charges,,,,,,,,,71.61,,,percent of total billed charges,,,39.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,37.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.73,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.28,,,percent of total billed charges,,
GENTAMICIN 0.3  OP SOLN 5 ML,2500011526,CDM,637,RC,6131463305,NDC,,,,,,outpatient,facility,5,UN,71.61,71.61,5.73,618.77,,41.82,,,percent of total billed charges,,,13.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,71.61,,,percent of total billed charges,,,63.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,63.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,63.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,26.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,64.45,,,percent of total billed charges,,,,,,,,,71.61,,,percent of total billed charges,,,48.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55,,,percent of total billed charges,,,,,,,,,,,,,,,38.67,,,percent of total billed charges,,,38.67,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.34,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.42,,,percent of total billed charges,,,27.13,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,14.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,26.5,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,71.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,71.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.73,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,,,,,,,71.61,,,fee schedule,,,66.61,,,percent of total billed charges,,,,,,,,,,,,,,,66.61,,,percent of total billed charges,,,66.61,,,percent of total billed charges,,,66.61,,,percent of total billed charges,,,53.71,,,percent of total billed charges,,,71.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,71.61,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,50.28,,,percent of total billed charges,,
GENTAMICIN 0.3  OP SOLN 5 ML,2500011526,CDM,637,RC,6131463305,NDC,999,EAPG,,,,outpatient,facility,5,UN,71.61,71.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLIPIZIDE 5 MG TAB,2500011552,CDM,637,RC,904663761,NDC,,,,,,inpatient,facility,5,UN,1.09,1.09,0.09,1.09,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,
GLIPIZIDE 5 MG TAB,2500011552,CDM,637,RC,904663761,NDC,,,,,,outpatient,facility,5,UN,1.09,1.09,0.09,618.77,,0.64,,,percent of total billed charges,,,0.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.09,,,percent of total billed charges,,,0.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.98,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,1.09,,,fee schedule,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,1.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.77,,,percent of total billed charges,,
GLIPIZIDE 5 MG TAB,2500011552,CDM,637,RC,904663761,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.09,1.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLUCOSE 15 GM TUBE,2500011561,CDM,637,RC,574006915,NDC,,,,,,inpatient,facility,15,UN,2.37,2.37,0.19,2.37,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,,,,,,,2.37,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,
GLUCOSE 15 GM TUBE,2500011561,CDM,637,RC,574006915,NDC,,,,,,outpatient,facility,15,UN,2.37,2.37,0.19,618.77,,1.38,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.37,,,percent of total billed charges,,,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.13,,,percent of total billed charges,,,,,,,,,2.37,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,0.9,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.88,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,2.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,2.37,,,fee schedule,,,2.2,,,percent of total billed charges,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,2.2,,,percent of total billed charges,,,2.2,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,2.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.66,,,percent of total billed charges,,
GLUCOSE 15 GM TUBE,2500011561,CDM,637,RC,574006915,NDC,999,EAPG,,,,outpatient,facility,15,UN,2.37,2.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLYCERIN PEDIATRIC SUPP,2500011590,CDM,637,RC,132008112,NDC,,,,,,inpatient,facility,1,UN,0.03,0.03,0.01,0.03,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,0.03,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,
GLYCERIN PEDIATRIC SUPP,2500011590,CDM,637,RC,132008112,NDC,,,,,,outpatient,facility,1,UN,0.03,0.03,0.01,618.77,,0.02,,,percent of total billed charges,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.03,,,percent of total billed charges,,,,,,,,,0.03,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,0.03,,,fee schedule,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,0.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.02,,,percent of total billed charges,,
GLYCERIN PEDIATRIC SUPP,2500011590,CDM,637,RC,132008112,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.03,0.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLYCOPYRROLATE 1 MG TAB,2500011593,CDM,637,RC,2315560601,NDC,,,,,,inpatient,facility,1,UN,4.32,4.32,0.35,4.32,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,,,,,,,4.32,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,2.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,
GLYCOPYRROLATE 1 MG TAB,2500011593,CDM,637,RC,2315560601,NDC,,,,,,outpatient,facility,1,UN,4.32,4.32,0.35,618.77,,2.52,,,percent of total billed charges,,,0.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.32,,,percent of total billed charges,,,3.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.89,,,percent of total billed charges,,,,,,,,,4.32,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.32,,,percent of total billed charges,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.28,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.6,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,4.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.35,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,4.32,,,fee schedule,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,4.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.32,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.03,,,percent of total billed charges,,
GLYCOPYRROLATE 1 MG TAB,2500011593,CDM,637,RC,2315560601,NDC,999,EAPG,,,,outpatient,facility,1,UN,4.32,4.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLYCOPYRROLATE 0.2MG/ML2ML INJ,2500011594,CDM,250,RC,J3490,HCPCS,7070016625,NDC,,,,inpatient,facility,2,UN,68.54,68.54,5.48,68.54,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.69,,,percent of total billed charges,,,,,,,,,68.54,,,percent of total billed charges,,,37.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,35.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.13,,,percent of total billed charges,,
GLYCOPYRROLATE 0.2MG/ML2ML INJ,2500011594,CDM,250,RC,J3490,HCPCS,7070016625,NDC,,,,outpatient,facility,2,UN,68.54,68.54,1.2,618.77,,40.03,,,percent of total billed charges,,,13.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,68.54,,,percent of total billed charges,,,60.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,60.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,60.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,25.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,61.69,,,percent of total billed charges,,,,,,,,,68.54,,,percent of total billed charges,,,46.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.64,,,percent of total billed charges,,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.74,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.09,,,percent of total billed charges,,,25.96,,,percent of total billed charges,,,35.5,,,percent of total billed charges,,,,,,,,,,,,,,,13.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,68.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,68.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.48,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,68.54,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,51.41,,,percent of total billed charges,,,68.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,68.54,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,48.13,,,percent of total billed charges,,
GLYCOPYRROLATE 0.2MG/ML2ML INJ,2500011594,CDM,250,RC,J3490,HCPCS,7070016625,NDC,435,EAPG,,outpatient,facility,2,UN,68.54,68.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLYCOPYRROLATE 0.2MG/ML5ML INJ,2500011596,CDM,250,RC,J3490,HCPCS,7070016725,NDC,,,,inpatient,facility,5,UN,147.74,147.74,11.82,147.74,,,,,,,,,,,,,,147.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.97,,,percent of total billed charges,,,,,,,,,147.74,,,percent of total billed charges,,,81.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.74,,,percent of total billed charges,,,,,,,,,,,,,,,147.74,,,percent of total billed charges,,,77.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.82,,,percent of total billed charges,,,147.74,,,percent of total billed charges,,,147.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,147.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.74,,,percent of total billed charges,,
GLYCOPYRROLATE 0.2MG/ML5ML INJ,2500011596,CDM,250,RC,J3490,HCPCS,7070016725,NDC,,,,outpatient,facility,5,UN,147.74,147.74,1.2,618.77,,86.28,,,percent of total billed charges,,,28.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,147.74,,,percent of total billed charges,,,130.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,130.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,130.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,147.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,54.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,132.97,,,percent of total billed charges,,,,,,,,,147.74,,,percent of total billed charges,,,100.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.46,,,percent of total billed charges,,,,,,,,,,,,,,,147.74,,,percent of total billed charges,,,147.74,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,147.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.03,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.28,,,percent of total billed charges,,,55.96,,,percent of total billed charges,,,76.51,,,percent of total billed charges,,,,,,,,,,,,,,,29.55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,147.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,147.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.82,,,percent of total billed charges,,,147.74,,,percent of total billed charges,,,147.74,,,percent of total billed charges,,,,,,,,,,,,,,,147.74,,,percent of total billed charges,,,147.74,,,percent of total billed charges,,,,,,,,,147.74,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,110.81,,,percent of total billed charges,,,147.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,147.74,,,percent of total billed charges,,,147.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,103.74,,,percent of total billed charges,,
GLYCOPYRROLATE 0.2MG/ML5ML INJ,2500011596,CDM,250,RC,J3490,HCPCS,7070016725,NDC,435,EAPG,,outpatient,facility,5,UN,147.74,147.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLYCOPYRROLATE 0.2MG/ML INJ,2500011597,CDM,250,RC,517460125,NDC,,,,,,inpatient,facility,1,ML,42.9,42.9,3.43,42.9,,,,,,,,,,,,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.61,,,percent of total billed charges,,,,,,,,,42.9,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,42.9,,,percent of total billed charges,,,22.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.12,,,percent of total billed charges,,
GLYCOPYRROLATE 0.2MG/ML INJ,2500011597,CDM,250,RC,517460125,NDC,,,,,,outpatient,facility,1,ML,42.9,42.9,3.43,618.77,,25.05,,,percent of total billed charges,,,8.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,42.9,,,percent of total billed charges,,,37.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,37.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,37.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,15.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,38.61,,,percent of total billed charges,,,,,,,,,42.9,,,percent of total billed charges,,,29.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.37,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.6,,,percent of total billed charges,,,16.25,,,percent of total billed charges,,,22.22,,,percent of total billed charges,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,17.16,,,percent of total billed charges,,,17.16,,,percent of total billed charges,,,42.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,42.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.43,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,42.9,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,,,,,,,42.9,,,fee schedule,,,17.16,,,percent of total billed charges,,,,,,,,,,,,,,,17.16,,,percent of total billed charges,,,17.16,,,percent of total billed charges,,,17.16,,,percent of total billed charges,,,32.17,,,percent of total billed charges,,,42.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,42.9,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,30.12,,,percent of total billed charges,,
GLYCOPYRROLATE 0.2MG/ML INJ,2500011597,CDM,250,RC,517460125,NDC,999,EAPG,,,,outpatient,facility,1,ML,42.9,42.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GOLYTELY 4000 ML,2500011610,CDM,637,RC,5226810001,NDC,,,,,,inpatient,facility,4000,UN,82.1,82.1,6.57,82.1,,,,,,,,,,,,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.89,,,percent of total billed charges,,,,,,,,,82.1,,,percent of total billed charges,,,45.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,82.1,,,percent of total billed charges,,,42.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.65,,,percent of total billed charges,,
GOLYTELY 4000 ML,2500011610,CDM,637,RC,5226810001,NDC,,,,,,outpatient,facility,4000,UN,82.1,82.1,6.57,618.77,,47.95,,,percent of total billed charges,,,16.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,82.1,,,percent of total billed charges,,,72.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,72.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,72.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,30.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,73.89,,,percent of total billed charges,,,,,,,,,82.1,,,percent of total billed charges,,,55.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.05,,,percent of total billed charges,,,,,,,,,,,,,,,44.33,,,percent of total billed charges,,,44.33,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.81,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.4,,,percent of total billed charges,,,31.1,,,percent of total billed charges,,,42.52,,,percent of total billed charges,,,,,,,,,,,,,,,16.42,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,30.38,,,percent of total billed charges,,,30.38,,,percent of total billed charges,,,82.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,82.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.57,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,82.1,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,,,,,,,82.1,,,fee schedule,,,76.37,,,percent of total billed charges,,,,,,,,,,,,,,,76.37,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,61.57,,,percent of total billed charges,,,82.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,82.1,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,57.65,,,percent of total billed charges,,
GOLYTELY 4000 ML,2500011610,CDM,637,RC,5226810001,NDC,999,EAPG,,,,outpatient,facility,4000,UN,82.1,82.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUAIFENESIN/DM LIQ 10 ML UDC,2500011650,CDM,637,RC,121127600,NDC,,,,,,inpatient,facility,10,UN,4.16,4.16,0.33,4.16,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,,,,,,,,4.16,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,
GUAIFENESIN/DM LIQ 10 ML UDC,2500011650,CDM,637,RC,121127600,NDC,,,,,,outpatient,facility,10,UN,4.16,4.16,0.33,618.77,,2.43,,,percent of total billed charges,,,0.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.16,,,percent of total billed charges,,,3.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.74,,,percent of total billed charges,,,,,,,,,4.16,,,percent of total billed charges,,,2.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,,2.25,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.54,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,4.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.33,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,4.16,,,fee schedule,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,3.12,,,percent of total billed charges,,,4.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.16,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.92,,,percent of total billed charges,,
GUAIFENESIN/DM LIQ 10 ML UDC,2500011650,CDM,637,RC,121127600,NDC,999,EAPG,,,,outpatient,facility,10,UN,4.16,4.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUAIFENESIN 200 MG/10 ML UDC,2500011656,CDM,637,RC,121148800,NDC,,,,,,inpatient,facility,10,UN,2.9,2.9,0.23,2.9,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,2.9,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,
GUAIFENESIN 200 MG/10 ML UDC,2500011656,CDM,637,RC,121148800,NDC,,,,,,outpatient,facility,10,UN,2.9,2.9,0.23,618.77,,1.69,,,percent of total billed charges,,,0.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.9,,,percent of total billed charges,,,2.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.61,,,percent of total billed charges,,,,,,,,,2.9,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.07,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,2.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,2.9,,,fee schedule,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.04,,,percent of total billed charges,,
GUAIFENESIN 200 MG/10 ML UDC,2500011656,CDM,637,RC,121148800,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.9,2.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUAIFENESIN LA 600 MG TAB,2500011658,CDM,637,RC,904671839,NDC,,,,,,inpatient,facility,600,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
GUAIFENESIN LA 600 MG TAB,2500011658,CDM,637,RC,904671839,NDC,,,,,,outpatient,facility,600,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
GUAIFENESIN LA 600 MG TAB,2500011658,CDM,637,RC,904671839,NDC,999,EAPG,,,,outpatient,facility,600,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUAIFENESIN/COD ORAL 5 ML UDC,2500011661,CDM,637,RC,121177500,NDC,,,,,,inpatient,facility,5,UN,2.13,2.13,0.17,2.13,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,2.13,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,
GUAIFENESIN/COD ORAL 5 ML UDC,2500011661,CDM,637,RC,121177500,NDC,,,,,,outpatient,facility,5,UN,2.13,2.13,0.17,618.77,,1.24,,,percent of total billed charges,,,0.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.13,,,percent of total billed charges,,,1.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.92,,,percent of total billed charges,,,,,,,,,2.13,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,2.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,2.13,,,fee schedule,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,2.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.13,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.5,,,percent of total billed charges,,
GUAIFENESIN/COD ORAL 5 ML UDC,2500011661,CDM,637,RC,121177500,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.13,2.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUANFACINE HCL 1 MG TAB,2500011685,CDM,637,RC,591044401,NDC,,,,,,inpatient,facility,1,UN,2.87,2.87,0.23,2.87,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,,,,,,,2.87,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,
GUANFACINE HCL 1 MG TAB,2500011685,CDM,637,RC,591044401,NDC,,,,,,outpatient,facility,1,UN,2.87,2.87,0.23,618.77,,1.68,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.87,,,percent of total billed charges,,,2.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.58,,,percent of total billed charges,,,,,,,,,2.87,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.06,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,2.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,2.87,,,fee schedule,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.02,,,percent of total billed charges,,
GUANFACINE HCL 1 MG TAB,2500011685,CDM,637,RC,591044401,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.87,2.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HALOPERIDOL 1 MG TAB,2500011701,CDM,637,RC,5107973420,NDC,,,,,,inpatient,facility,1,UN,1.61,1.61,0.13,1.61,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,
HALOPERIDOL 1 MG TAB,2500011701,CDM,637,RC,5107973420,NDC,,,,,,outpatient,facility,1,UN,1.61,1.61,0.13,618.77,,0.94,,,percent of total billed charges,,,0.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.61,,,percent of total billed charges,,,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.45,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.6,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,1.61,,,fee schedule,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,1.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.13,,,percent of total billed charges,,
HALOPERIDOL 1 MG TAB,2500011701,CDM,637,RC,5107973420,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.61,1.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HALOPERIDOL 10 MG TAB,2500011702,CDM,637,RC,904673361,NDC,,,,,,inpatient,facility,10,UN,3.8,3.8,0.3,3.8,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.42,,,percent of total billed charges,,,,,,,,,3.8,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,
HALOPERIDOL 10 MG TAB,2500011702,CDM,637,RC,904673361,NDC,,,,,,outpatient,facility,10,UN,3.8,3.8,0.3,618.77,,2.22,,,percent of total billed charges,,,0.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.8,,,percent of total billed charges,,,3.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.42,,,percent of total billed charges,,,,,,,,,3.8,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,3.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.3,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,3.8,,,fee schedule,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,3.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.8,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.67,,,percent of total billed charges,,
HALOPERIDOL 10 MG TAB,2500011702,CDM,637,RC,904673361,NDC,999,EAPG,,,,outpatient,facility,10,UN,3.8,3.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HALOPERIDOL 5 MG TAB,2500011706,CDM,637,RC,904678261,NDC,,,,,,inpatient,facility,5,UN,2.51,2.51,0.2,2.51,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,2.51,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,
HALOPERIDOL 5 MG TAB,2500011706,CDM,637,RC,904678261,NDC,,,,,,outpatient,facility,5,UN,2.51,2.51,0.2,618.77,,1.47,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.51,,,percent of total billed charges,,,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.26,,,percent of total billed charges,,,,,,,,,2.51,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.93,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,2.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,2.51,,,fee schedule,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,2.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.76,,,percent of total billed charges,,
HALOPERIDOL 5 MG TAB,2500011706,CDM,637,RC,904678261,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.51,2.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HALOPERIDOL ORAL 10MG/5ML UDC,2500011716,CDM,637,RC,121058105,NDC,,,,,,inpatient,facility,5,UN,13.83,13.83,1.11,13.83,,,,,,,,,,,,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.45,,,percent of total billed charges,,,,,,,,,13.83,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,13.83,,,percent of total billed charges,,,7.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.71,,,percent of total billed charges,,
HALOPERIDOL ORAL 10MG/5ML UDC,2500011716,CDM,637,RC,121058105,NDC,,,,,,outpatient,facility,5,UN,13.83,13.83,1.11,618.77,,8.08,,,percent of total billed charges,,,2.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.83,,,percent of total billed charges,,,12.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.45,,,percent of total billed charges,,,,,,,,,13.83,,,percent of total billed charges,,,9.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.62,,,percent of total billed charges,,,,,,,,,,,,,,,7.47,,,percent of total billed charges,,,7.47,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.21,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.51,,,percent of total billed charges,,,5.24,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.12,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,13.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.11,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,13.83,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,,,,,,,13.83,,,fee schedule,,,12.86,,,percent of total billed charges,,,,,,,,,,,,,,,12.86,,,percent of total billed charges,,,12.86,,,percent of total billed charges,,,12.86,,,percent of total billed charges,,,10.37,,,percent of total billed charges,,,13.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.83,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.71,,,percent of total billed charges,,
HALOPERIDOL ORAL 10MG/5ML UDC,2500011716,CDM,637,RC,121058105,NDC,999,EAPG,,,,outpatient,facility,5,UN,13.83,13.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEMORRHOIDAL PREP OINT 60 GM,2500011800,CDM,637,RC,536128806,NDC,,,,,,inpatient,facility,60,UN,3.87,3.87,0.31,3.87,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,,,,,,,,3.87,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,
HEMORRHOIDAL PREP OINT 60 GM,2500011800,CDM,637,RC,536128806,NDC,,,,,,outpatient,facility,60,UN,3.87,3.87,0.31,618.77,,2.26,,,percent of total billed charges,,,0.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.87,,,percent of total billed charges,,,3.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.48,,,percent of total billed charges,,,,,,,,,3.87,,,percent of total billed charges,,,2.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.09,,,percent of total billed charges,,,2.09,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.43,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,3.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.31,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,3.87,,,fee schedule,,,3.6,,,percent of total billed charges,,,,,,,,,,,,,,,3.6,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,3.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.87,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.72,,,percent of total billed charges,,
HEMORRHOIDAL PREP OINT 60 GM,2500011800,CDM,637,RC,536128806,NDC,999,EAPG,,,,outpatient,facility,60,UN,3.87,3.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDRALAZINE HCL 10 MG TAB,2500011940,CDM,637,RC,904644061,NDC,,,,,,inpatient,facility,10,UN,0.33,0.33,0.03,0.33,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,0.33,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,
HYDRALAZINE HCL 10 MG TAB,2500011940,CDM,637,RC,904644061,NDC,,,,,,outpatient,facility,10,UN,0.33,0.33,0.03,618.77,,0.19,,,percent of total billed charges,,,0.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.33,,,percent of total billed charges,,,0.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.3,,,percent of total billed charges,,,,,,,,,0.33,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.12,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,0.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,0.33,,,fee schedule,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,0.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.23,,,percent of total billed charges,,
HYDRALAZINE HCL 10 MG TAB,2500011940,CDM,637,RC,904644061,NDC,999,EAPG,,,,outpatient,facility,10,UN,0.33,0.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDRALAZINE HCL 25 MG TAB,2500011943,CDM,637,RC,904644161,NDC,,,,,,inpatient,facility,25,UN,0.39,0.39,0.03,0.39,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,
HYDRALAZINE HCL 25 MG TAB,2500011943,CDM,637,RC,904644161,NDC,,,,,,outpatient,facility,25,UN,0.39,0.39,0.03,618.77,,0.23,,,percent of total billed charges,,,0.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.39,,,percent of total billed charges,,,0.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.35,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.14,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,0.39,,,fee schedule,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.27,,,percent of total billed charges,,
HYDRALAZINE HCL 25 MG TAB,2500011943,CDM,637,RC,904644161,NDC,999,EAPG,,,,outpatient,facility,25,UN,0.39,0.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCHLOROTHIAZIDE 25 MG TAB,2500011962,CDM,637,RC,1672918317,NDC,,,,,,inpatient,facility,25,UN,0.26,0.26,0.02,0.26,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,
HYDROCHLOROTHIAZIDE 25 MG TAB,2500011962,CDM,637,RC,1672918317,NDC,,,,,,outpatient,facility,25,UN,0.26,0.26,0.02,618.77,,0.15,,,percent of total billed charges,,,0.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,0.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.23,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.1,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,0.26,,,fee schedule,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.18,,,percent of total billed charges,,
HYDROCHLOROTHIAZIDE 25 MG TAB,2500011962,CDM,637,RC,1672918317,NDC,999,EAPG,,,,outpatient,facility,25,UN,0.26,0.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORTISONE 0.5  CR 30 GM,2500012000,CDM,637,RC,5167220102,NDC,,,,,,inpatient,facility,30,UN,8.72,8.72,0.7,8.72,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,,,,,,,8.72,,,percent of total billed charges,,,4.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,
HYDROCORTISONE 0.5  CR 30 GM,2500012000,CDM,637,RC,5167220102,NDC,,,,,,outpatient,facility,30,UN,8.72,8.72,0.7,618.77,,5.09,,,percent of total billed charges,,,1.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.72,,,percent of total billed charges,,,7.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.85,,,percent of total billed charges,,,,,,,,,8.72,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,4.71,,,percent of total billed charges,,,4.71,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,4.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,8.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.7,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,8.72,,,fee schedule,,,8.11,,,percent of total billed charges,,,,,,,,,,,,,,,8.11,,,percent of total billed charges,,,8.11,,,percent of total billed charges,,,8.11,,,percent of total billed charges,,,6.54,,,percent of total billed charges,,,8.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.72,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.12,,,percent of total billed charges,,
HYDROCORTISONE 0.5  CR 30 GM,2500012000,CDM,637,RC,5167220102,NDC,999,EAPG,,,,outpatient,facility,30,UN,8.72,8.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORTISONE 1  CR 30 GM,2500012005,CDM,637,RC,904762331,NDC,,,,,,inpatient,facility,30,UN,5.08,5.08,0.41,5.08,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.57,,,percent of total billed charges,,,,,,,,,5.08,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.57,,,percent of total billed charges,,
HYDROCORTISONE 1  CR 30 GM,2500012005,CDM,637,RC,904762331,NDC,,,,,,outpatient,facility,30,UN,5.08,5.08,0.41,618.77,,2.97,,,percent of total billed charges,,,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.08,,,percent of total billed charges,,,4.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.57,,,percent of total billed charges,,,,,,,,,5.08,,,percent of total billed charges,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.86,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,5.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.41,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,,,,,,,5.08,,,fee schedule,,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,4.73,,,percent of total billed charges,,,4.73,,,percent of total billed charges,,,4.73,,,percent of total billed charges,,,3.81,,,percent of total billed charges,,,5.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.08,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.57,,,percent of total billed charges,,
HYDROCORTISONE 1  CR 30 GM,2500012005,CDM,637,RC,904762331,NDC,999,EAPG,,,,outpatient,facility,30,UN,5.08,5.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORTISONE 1  OINT 30 GM,2500012007,CDM,637,RC,4580227603,NDC,,,,,,inpatient,facility,30,UN,7.43,7.43,0.59,7.43,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.69,,,percent of total billed charges,,,,,,,,,7.43,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,
HYDROCORTISONE 1  OINT 30 GM,2500012007,CDM,637,RC,4580227603,NDC,,,,,,outpatient,facility,30,UN,7.43,7.43,0.59,618.77,,4.34,,,percent of total billed charges,,,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.43,,,percent of total billed charges,,,6.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.69,,,percent of total billed charges,,,,,,,,,7.43,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,4.01,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.65,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.75,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,7.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,7.43,,,fee schedule,,,6.91,,,percent of total billed charges,,,,,,,,,,,,,,,6.91,,,percent of total billed charges,,,6.91,,,percent of total billed charges,,,6.91,,,percent of total billed charges,,,5.57,,,percent of total billed charges,,,7.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.43,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.22,,,percent of total billed charges,,
HYDROCORTISONE 1  OINT 30 GM,2500012007,CDM,637,RC,4580227603,NDC,999,EAPG,,,,outpatient,facility,30,UN,7.43,7.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORTISONE 2.5  CR 30 GM,2500012012,CDM,637,RC,168008031,NDC,,,,,,inpatient,facility,30,UN,36.3,36.3,2.9,36.3,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.67,,,percent of total billed charges,,,,,,,,,36.3,,,percent of total billed charges,,,20.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,18.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.49,,,percent of total billed charges,,
HYDROCORTISONE 2.5  CR 30 GM,2500012012,CDM,637,RC,168008031,NDC,,,,,,outpatient,facility,30,UN,36.3,36.3,2.9,618.77,,21.2,,,percent of total billed charges,,,7.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,36.3,,,percent of total billed charges,,,31.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,31.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,31.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,13.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,32.67,,,percent of total billed charges,,,,,,,,,36.3,,,percent of total billed charges,,,24.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.88,,,percent of total billed charges,,,,,,,,,,,,,,,19.6,,,percent of total billed charges,,,19.6,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.93,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,13.75,,,percent of total billed charges,,,18.8,,,percent of total billed charges,,,,,,,,,,,,,,,7.26,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,13.43,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,36.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,36.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.9,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,,,,,,,36.3,,,fee schedule,,,33.77,,,percent of total billed charges,,,,,,,,,,,,,,,33.77,,,percent of total billed charges,,,33.77,,,percent of total billed charges,,,33.77,,,percent of total billed charges,,,27.22,,,percent of total billed charges,,,36.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,36.3,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,25.49,,,percent of total billed charges,,
HYDROCORTISONE 2.5  CR 30 GM,2500012012,CDM,637,RC,168008031,NDC,999,EAPG,,,,outpatient,facility,30,UN,36.3,36.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORTISONE 10 MG TAB,2500012021,CDM,637,RC,7278909401,NDC,,,,,,inpatient,facility,10,UN,1.61,1.61,0.13,1.61,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,
HYDROCORTISONE 10 MG TAB,2500012021,CDM,637,RC,7278909401,NDC,,,,,,outpatient,facility,10,UN,1.61,1.61,0.13,618.77,,0.94,,,percent of total billed charges,,,0.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.61,,,percent of total billed charges,,,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.45,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.6,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,1.61,,,fee schedule,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,1.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.13,,,percent of total billed charges,,
HYDROCORTISONE 10 MG TAB,2500012021,CDM,637,RC,7278909401,NDC,999,EAPG,,,,outpatient,facility,10,UN,1.61,1.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORTISONE 25 MG SUPP,2500012023,CDM,637,RC,713050312,NDC,,,,,,inpatient,facility,25,UN,74.75,74.75,5.98,74.75,,,,,,,,,,,,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.28,,,percent of total billed charges,,,,,,,,,74.75,,,percent of total billed charges,,,41.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,74.75,,,percent of total billed charges,,,38.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.98,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.49,,,percent of total billed charges,,
HYDROCORTISONE 25 MG SUPP,2500012023,CDM,637,RC,713050312,NDC,,,,,,outpatient,facility,25,UN,74.75,74.75,5.98,618.77,,43.65,,,percent of total billed charges,,,14.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,74.75,,,percent of total billed charges,,,65.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,65.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,65.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,27.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,67.28,,,percent of total billed charges,,,,,,,,,74.75,,,percent of total billed charges,,,50.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.41,,,percent of total billed charges,,,,,,,,,,,,,,,40.37,,,percent of total billed charges,,,40.37,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.97,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.81,,,percent of total billed charges,,,28.32,,,percent of total billed charges,,,38.71,,,percent of total billed charges,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,27.66,,,percent of total billed charges,,,27.66,,,percent of total billed charges,,,74.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,74.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.98,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,74.75,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,,,,,,,74.75,,,fee schedule,,,69.53,,,percent of total billed charges,,,,,,,,,,,,,,,69.53,,,percent of total billed charges,,,69.53,,,percent of total billed charges,,,69.53,,,percent of total billed charges,,,56.06,,,percent of total billed charges,,,74.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,74.75,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,52.49,,,percent of total billed charges,,
HYDROCORTISONE 25 MG SUPP,2500012023,CDM,637,RC,713050312,NDC,999,EAPG,,,,outpatient,facility,25,UN,74.75,74.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORTISONE FOAM 15 GM CAN,2500012032,CDM,637,RC,37683015,NDC,,,,,,inpatient,facility,15,UN,1378.44,1378.44,110.28,1378.44,,,,,,,,,,,,,,1378.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1240.6,,,percent of total billed charges,,,,,,,,,1378.44,,,percent of total billed charges,,,763.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1257.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1378.44,,,percent of total billed charges,,,,,,,,,,,,,,,1378.44,,,percent of total billed charges,,,718.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,275.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.28,,,percent of total billed charges,,,1378.44,,,percent of total billed charges,,,1378.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1378.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,967.94,,,percent of total billed charges,,
HYDROCORTISONE FOAM 15 GM CAN,2500012032,CDM,637,RC,37683015,NDC,,,,,,outpatient,facility,15,UN,1378.44,1378.44,110.28,1378.44,,805.01,,,percent of total billed charges,,,268.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1378.44,,,percent of total billed charges,,,1213.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1213.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1213.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1378.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,504.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1240.6,,,percent of total billed charges,,,,,,,,,1378.44,,,percent of total billed charges,,,933.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1058.64,,,percent of total billed charges,,,,,,,,,,,,,,,744.36,,,percent of total billed charges,,,744.36,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1378.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,718.72,,,percent of total billed charges,,,1378.44,,,percent of total billed charges,,,1378.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1047.61,,,percent of total billed charges,,,522.15,,,percent of total billed charges,,,713.89,,,percent of total billed charges,,,,,,,,,,,,,,,275.69,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,510.02,,,percent of total billed charges,,,510.02,,,percent of total billed charges,,,1378.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1378.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,110.28,,,percent of total billed charges,,,1378.44,,,percent of total billed charges,,,1378.44,,,percent of total billed charges,,,,,,,,,,,,,,,1378.44,,,percent of total billed charges,,,1378.44,,,percent of total billed charges,,,,,,,,,1378.44,,,fee schedule,,,1282.22,,,percent of total billed charges,,,,,,,,,,,,,,,1282.22,,,percent of total billed charges,,,1282.22,,,percent of total billed charges,,,1282.22,,,percent of total billed charges,,,1033.83,,,percent of total billed charges,,,1378.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1378.44,,,percent of total billed charges,,,1378.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,689.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,967.94,,,percent of total billed charges,,
HYDROCORTISONE FOAM 15 GM CAN,2500012032,CDM,637,RC,37683015,NDC,999,EAPG,,,,outpatient,facility,15,UN,1378.44,1378.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROMORPHONE 2 MG TAB,2500012072,CDM,637,RC,4285830125,NDC,,,,,,inpatient,facility,2,UN,0.56,0.56,0.04,0.56,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,
HYDROMORPHONE 2 MG TAB,2500012072,CDM,637,RC,4285830125,NDC,,,,,,outpatient,facility,2,UN,0.56,0.56,0.04,618.77,,0.33,,,percent of total billed charges,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.5,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.56,,,fee schedule,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,0.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.39,,,percent of total billed charges,,
HYDROMORPHONE 2 MG TAB,2500012072,CDM,637,RC,4285830125,NDC,999,EAPG,,,,outpatient,facility,2,UN,0.56,0.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROMORPHONE 0.5 MG/0.5ML INJ,2500012076,CDM,636,RC,J1171,HCPCS,409426401,NDC,,,,inpatient,facility,0.5,ML,10.52,10.52,0.84,10.52,,,,,,,,,,,,,,10.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,,,,,,,,10.52,,,percent of total billed charges,,,5.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.52,,,percent of total billed charges,,,,,,,,,,,,,,,10.52,,,percent of total billed charges,,,5.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,10.52,,,percent of total billed charges,,,10.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,
HYDROMORPHONE 0.5 MG/0.5ML INJ,2500012076,CDM,636,RC,J1171,HCPCS,409426401,NDC,,,,outpatient,facility,0.5,ML,10.52,10.52,0.84,618.77,,6.14,,,percent of total billed charges,,,,,,,,,10.52,,,percent of total billed charges,,,9.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,9.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,9.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.47,,,percent of total billed charges,,,,,,,,,10.52,,,percent of total billed charges,,,7.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.08,,,percent of total billed charges,,,,,,,,,,,,,,,5.68,,,percent of total billed charges,,,5.68,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,10.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.49,,,percent of total billed charges,,,10.52,,,percent of total billed charges,,,10.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,5.45,,,percent of total billed charges,,,,,,,,,,,,,,,2.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.89,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,10.52,,,percent of total billed charges,,,10.52,,,percent of total billed charges,,,,,,,,,,,,,,,10.52,,,percent of total billed charges,,,10.52,,,percent of total billed charges,,,,,,,,,10.52,,,fee schedule,,,9.79,,,percent of total billed charges,,,,,,,,,,,,,,,9.79,,,percent of total billed charges,,,9.79,,,percent of total billed charges,,,9.79,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,10.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.52,,,percent of total billed charges,,,10.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.26,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.39,,,percent of total billed charges,,
HYDROMORPHONE 0.5 MG/0.5ML INJ,2500012076,CDM,636,RC,J1171,HCPCS,409426401,NDC,791,APC,,outpatient,facility,0.5,ML,10.52,10.52,0.09,3.85,,,,,,,,0.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,3.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.13,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.1,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,
HYDROMORPHONE 0.5 MG/0.5ML INJ,2500012076,CDM,636,RC,J1171,HCPCS,409426401,NDC,999,EAPG,,outpatient,facility,0.5,ML,10.52,10.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROXYCHLOROQUINE 200 MG TAB,2500012080,CDM,637,RC,1054457890,NDC,,,,,,inpatient,facility,8,UN,13.49,13.49,1.08,13.49,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,13.49,,,percent of total billed charges,,,7.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,
HYDROXYCHLOROQUINE 200 MG TAB,2500012080,CDM,637,RC,1054457890,NDC,,,,,,outpatient,facility,8,UN,13.49,13.49,1.08,618.77,,7.88,,,percent of total billed charges,,,2.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.49,,,percent of total billed charges,,,11.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,11.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,11.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.14,,,percent of total billed charges,,,,,,,,,13.49,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,7.28,,,percent of total billed charges,,,7.28,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.25,,,percent of total billed charges,,,5.11,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.99,,,percent of total billed charges,,,4.99,,,percent of total billed charges,,,13.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.08,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,,,,,,,13.49,,,fee schedule,,,12.55,,,percent of total billed charges,,,,,,,,,,,,,,,12.55,,,percent of total billed charges,,,12.55,,,percent of total billed charges,,,12.55,,,percent of total billed charges,,,10.12,,,percent of total billed charges,,,13.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.49,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.47,,,percent of total billed charges,,
HYDROXYCHLOROQUINE 200 MG TAB,2500012080,CDM,637,RC,1054457890,NDC,999,EAPG,,,,outpatient,facility,8,UN,13.49,13.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROXYUREA 500 MG CAP,2500012110,CDM,637,RC,904693961,NDC,,,,,,inpatient,facility,500,UN,3.2,3.2,0.26,3.2,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.88,,,percent of total billed charges,,,,,,,,,3.2,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,
HYDROXYUREA 500 MG CAP,2500012110,CDM,637,RC,904693961,NDC,,,,,,outpatient,facility,500,UN,3.2,3.2,0.26,618.77,,1.87,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.2,,,percent of total billed charges,,,2.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.88,,,percent of total billed charges,,,,,,,,,3.2,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,3.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,3.2,,,fee schedule,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.25,,,percent of total billed charges,,
HYDROXYUREA 500 MG CAP,2500012110,CDM,637,RC,904693961,NDC,999,EAPG,,,,outpatient,facility,500,UN,3.2,3.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROXYZINE 10 MG TAB,2500012120,CDM,637,RC,6808425301,NDC,,,,,,inpatient,facility,10,UN,0.92,0.92,0.07,0.92,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,
HYDROXYZINE 10 MG TAB,2500012120,CDM,637,RC,6808425301,NDC,,,,,,outpatient,facility,10,UN,0.92,0.92,0.07,618.77,,0.54,,,percent of total billed charges,,,0.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,0.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.83,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.34,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,0.92,,,fee schedule,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.65,,,percent of total billed charges,,
HYDROXYZINE 10 MG TAB,2500012120,CDM,637,RC,6808425301,NDC,999,EAPG,,,,outpatient,facility,10,UN,0.92,0.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROXYZINE 25 MG TAB,2500012121,CDM,637,RC,904661761,NDC,,,,,,inpatient,facility,25,UN,0.82,0.82,0.07,0.82,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
HYDROXYZINE 25 MG TAB,2500012121,CDM,637,RC,904661761,NDC,,,,,,outpatient,facility,25,UN,0.82,0.82,0.07,618.77,,0.48,,,percent of total billed charges,,,0.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.82,,,percent of total billed charges,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.74,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,0.82,,,fee schedule,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.58,,,percent of total billed charges,,
HYDROXYZINE 25 MG TAB,2500012121,CDM,637,RC,904661761,NDC,999,EAPG,,,,outpatient,facility,25,UN,0.82,0.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYOSCYAMINE SULF 0.125 MG SL,2500012150,CDM,637,RC,4778101101,NDC,,,,,,inpatient,facility,0.125,UN,2.81,2.81,0.22,2.81,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,,,,,,,2.81,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,
HYOSCYAMINE SULF 0.125 MG SL,2500012150,CDM,637,RC,4778101101,NDC,,,,,,outpatient,facility,0.125,UN,2.81,2.81,0.22,618.77,,1.64,,,percent of total billed charges,,,0.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.81,,,percent of total billed charges,,,2.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.53,,,percent of total billed charges,,,,,,,,,2.81,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.04,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,2.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.22,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,2.81,,,fee schedule,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,2.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.81,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.97,,,percent of total billed charges,,
HYOSCYAMINE SULF 0.125 MG SL,2500012150,CDM,637,RC,4778101101,NDC,999,EAPG,,,,outpatient,facility,0.125,UN,2.81,2.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IBUPROFEN 200 MG TAB,2500012170,CDM,637,RC,904674740,NDC,,,,,,inpatient,facility,200,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
IBUPROFEN 200 MG TAB,2500012170,CDM,637,RC,904674740,NDC,,,,,,outpatient,facility,200,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
IBUPROFEN 200 MG TAB,2500012170,CDM,637,RC,904674740,NDC,999,EAPG,,,,outpatient,facility,200,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IBUPROFEN 400 MG TAB,2500012171,CDM,637,RC,6787731901,NDC,,,,,,inpatient,facility,400,UN,1.22,1.22,0.1,1.22,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,
IBUPROFEN 400 MG TAB,2500012171,CDM,637,RC,6787731901,NDC,,,,,,outpatient,facility,400,UN,1.22,1.22,0.1,618.77,,0.71,,,percent of total billed charges,,,0.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.22,,,percent of total billed charges,,,1.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.1,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.45,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,1.22,,,fee schedule,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,1.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.86,,,percent of total billed charges,,
IBUPROFEN 400 MG TAB,2500012171,CDM,637,RC,6787731901,NDC,999,EAPG,,,,outpatient,facility,400,UN,1.22,1.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IBUPROFEN 800 MG TAB,2500012173,CDM,637,RC,904585561,NDC,,,,,,inpatient,facility,800,UN,0.23,0.23,0.02,0.23,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,
IBUPROFEN 800 MG TAB,2500012173,CDM,637,RC,904585561,NDC,,,,,,outpatient,facility,800,UN,0.23,0.23,0.02,618.77,,0.13,,,percent of total billed charges,,,0.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.21,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,0.09,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.09,,,percent of total billed charges,,,0.09,,,percent of total billed charges,,,0.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,0.23,,,fee schedule,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.16,,,percent of total billed charges,,
IBUPROFEN 800 MG TAB,2500012173,CDM,637,RC,904585561,NDC,999,EAPG,,,,outpatient,facility,800,UN,0.23,0.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IBUPROFEN 100 MG/5 ML UDC,2500012179,CDM,637,RC,6809449461,NDC,,,,,,inpatient,facility,5,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
IBUPROFEN 100 MG/5 ML UDC,2500012179,CDM,637,RC,6809449461,NDC,,,,,,outpatient,facility,5,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
IBUPROFEN 100 MG/5 ML UDC,2500012179,CDM,637,RC,6809449461,NDC,999,EAPG,,,,outpatient,facility,5,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMIPRAMINE HCL 10 MG TAB,2500012190,CDM,637,RC,4988405401,NDC,,,,,,inpatient,facility,10,UN,1.42,1.42,0.11,1.42,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,
IMIPRAMINE HCL 10 MG TAB,2500012190,CDM,637,RC,4988405401,NDC,,,,,,outpatient,facility,10,UN,1.42,1.42,0.11,618.77,,0.83,,,percent of total billed charges,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.42,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.28,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,1.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,1.42,,,fee schedule,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,1.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1,,,percent of total billed charges,,
IMIPRAMINE HCL 10 MG TAB,2500012190,CDM,637,RC,4988405401,NDC,999,EAPG,,,,outpatient,facility,10,UN,1.42,1.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMIPRAMINE HCL 25 MG TAB,2500012192,CDM,637,RC,4988405501,NDC,,,,,,inpatient,facility,25,UN,2.37,2.37,0.19,2.37,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,,,,,,,2.37,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,
IMIPRAMINE HCL 25 MG TAB,2500012192,CDM,637,RC,4988405501,NDC,,,,,,outpatient,facility,25,UN,2.37,2.37,0.19,618.77,,1.38,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.37,,,percent of total billed charges,,,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.13,,,percent of total billed charges,,,,,,,,,2.37,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,0.9,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.88,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,2.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,2.37,,,fee schedule,,,2.2,,,percent of total billed charges,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,2.2,,,percent of total billed charges,,,2.2,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,2.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.66,,,percent of total billed charges,,
IMIPRAMINE HCL 25 MG TAB,2500012192,CDM,637,RC,4988405501,NDC,999,EAPG,,,,outpatient,facility,25,UN,2.37,2.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INDOMETHACIN 25 MG CAP,2500012230,CDM,637,RC,7286514801,NDC,,,,,,inpatient,facility,25,UN,1.52,1.52,0.12,1.52,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,
INDOMETHACIN 25 MG CAP,2500012230,CDM,637,RC,7286514801,NDC,,,,,,outpatient,facility,25,UN,1.52,1.52,0.12,618.77,,0.89,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.52,,,percent of total billed charges,,,1.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.37,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,1.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,1.52,,,fee schedule,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,1.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.07,,,percent of total billed charges,,
INDOMETHACIN 25 MG CAP,2500012230,CDM,637,RC,7286514801,NDC,999,EAPG,,,,outpatient,facility,25,UN,1.52,1.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INDOMETHACIN 50 MG SUPP,2500012234,CDM,637,RC,6934410233,NDC,,,,,,inpatient,facility,50,UN,1194.3,1194.3,95.54,1194.3,,,,,,,,,,,,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1074.87,,,percent of total billed charges,,,,,,,,,1194.3,,,percent of total billed charges,,,661.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1089.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,1194.3,,,percent of total billed charges,,,622.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.54,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,838.64,,,percent of total billed charges,,
INDOMETHACIN 50 MG SUPP,2500012234,CDM,637,RC,6934410233,NDC,,,,,,outpatient,facility,50,UN,1194.3,1194.3,95.54,1194.3,,697.47,,,percent of total billed charges,,,232.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1194.3,,,percent of total billed charges,,,1051.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1051.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1051.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,437.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1074.87,,,percent of total billed charges,,,,,,,,,1194.3,,,percent of total billed charges,,,808.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,917.22,,,percent of total billed charges,,,,,,,,,,,,,,,644.92,,,percent of total billed charges,,,644.92,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,622.71,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,907.67,,,percent of total billed charges,,,452.4,,,percent of total billed charges,,,618.53,,,percent of total billed charges,,,,,,,,,,,,,,,238.86,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,441.89,,,percent of total billed charges,,,441.89,,,percent of total billed charges,,,1194.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1194.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,95.54,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,1194.3,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,,,,,,,1194.3,,,fee schedule,,,1110.94,,,percent of total billed charges,,,,,,,,,,,,,,,1110.94,,,percent of total billed charges,,,1110.94,,,percent of total billed charges,,,1110.94,,,percent of total billed charges,,,895.72,,,percent of total billed charges,,,1194.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1194.3,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,597.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,838.64,,,percent of total billed charges,,
INDOMETHACIN 50 MG SUPP,2500012234,CDM,637,RC,6934410233,NDC,999,EAPG,,,,outpatient,facility,50,UN,1194.3,1194.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IPRATROPIUM 0.03  NASAL 30 ML,2500012310,CDM,637,RC,54004544,NDC,,,,,,inpatient,facility,30,UN,368.51,368.51,29.48,368.51,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.66,,,percent of total billed charges,,,,,,,,,368.51,,,percent of total billed charges,,,204.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,192.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.48,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.77,,,percent of total billed charges,,
IPRATROPIUM 0.03  NASAL 30 ML,2500012310,CDM,637,RC,54004544,NDC,,,,,,outpatient,facility,30,UN,368.51,368.51,29.48,618.77,,215.21,,,percent of total billed charges,,,71.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,368.51,,,percent of total billed charges,,,324.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,324.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,324.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,134.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,331.66,,,percent of total billed charges,,,,,,,,,368.51,,,percent of total billed charges,,,249.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.02,,,percent of total billed charges,,,,,,,,,,,,,,,199,,,percent of total billed charges,,,199,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,192.14,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.07,,,percent of total billed charges,,,139.59,,,percent of total billed charges,,,190.85,,,percent of total billed charges,,,,,,,,,,,,,,,73.7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,136.35,,,percent of total billed charges,,,136.35,,,percent of total billed charges,,,368.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,368.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.48,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,,,,,,,368.51,,,fee schedule,,,342.79,,,percent of total billed charges,,,,,,,,,,,,,,,342.79,,,percent of total billed charges,,,342.79,,,percent of total billed charges,,,342.79,,,percent of total billed charges,,,276.38,,,percent of total billed charges,,,368.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,368.51,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,258.77,,,percent of total billed charges,,
IPRATROPIUM 0.03  NASAL 30 ML,2500012310,CDM,637,RC,54004544,NDC,999,EAPG,,,,outpatient,facility,30,UN,368.51,368.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISOSORBIDE DINITR 10 MG TAB,2500012410,CDM,637,RC,904661961,NDC,,,,,,inpatient,facility,10,UN,2.01,2.01,0.16,2.01,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,
ISOSORBIDE DINITR 10 MG TAB,2500012410,CDM,637,RC,904661961,NDC,,,,,,outpatient,facility,10,UN,2.01,2.01,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.01,,,percent of total billed charges,,,1.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.81,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,2.01,,,fee schedule,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,2.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.41,,,percent of total billed charges,,
ISOSORBIDE DINITR 10 MG TAB,2500012410,CDM,637,RC,904661961,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.01,2.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISOSORBIDE DINITR 20 MG TAB,2500012411,CDM,637,RC,904662061,NDC,,,,,,inpatient,facility,20,UN,2.34,2.34,0.19,2.34,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,2.34,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,
ISOSORBIDE DINITR 20 MG TAB,2500012411,CDM,637,RC,904662061,NDC,,,,,,outpatient,facility,20,UN,2.34,2.34,0.19,618.77,,1.37,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.34,,,percent of total billed charges,,,2.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.11,,,percent of total billed charges,,,,,,,,,2.34,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.87,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,2.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,2.34,,,fee schedule,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,2.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.64,,,percent of total billed charges,,
ISOSORBIDE DINITR 20 MG TAB,2500012411,CDM,637,RC,904662061,NDC,999,EAPG,,,,outpatient,facility,20,UN,2.34,2.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISOSORBIDE MONONIT 20 MG TAB,2500012421,CDM,637,RC,6217510701,NDC,,,,,,inpatient,facility,20,UN,2.08,2.08,0.17,2.08,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.46,,,percent of total billed charges,,
ISOSORBIDE MONONIT 20 MG TAB,2500012421,CDM,637,RC,6217510701,NDC,,,,,,outpatient,facility,20,UN,2.08,2.08,0.17,618.77,,1.21,,,percent of total billed charges,,,0.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.08,,,percent of total billed charges,,,1.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.87,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.77,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,2.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,2.08,,,fee schedule,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,2.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.46,,,percent of total billed charges,,
ISOSORBIDE MONONIT 20 MG TAB,2500012421,CDM,637,RC,6217510701,NDC,999,EAPG,,,,outpatient,facility,20,UN,2.08,2.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISOSORBIDE MONONIT 30 MG TABCR,2500012422,CDM,637,RC,904644961,NDC,,,,,,inpatient,facility,30,UN,1.25,1.25,0.1,1.25,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,
ISOSORBIDE MONONIT 30 MG TABCR,2500012422,CDM,637,RC,904644961,NDC,,,,,,outpatient,facility,30,UN,1.25,1.25,0.1,618.77,,0.73,,,percent of total billed charges,,,0.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.25,,,percent of total billed charges,,,1.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.13,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,1.25,,,fee schedule,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,1.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.88,,,percent of total billed charges,,
ISOSORBIDE MONONIT 30 MG TABCR,2500012422,CDM,637,RC,904644961,NDC,999,EAPG,,,,outpatient,facility,30,UN,1.25,1.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISOSORBIDE MONONIT 60 MG TABCR,2500012423,CDM,637,RC,904645061,NDC,,,,,,inpatient,facility,60,UN,1.35,1.35,0.11,1.35,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,
ISOSORBIDE MONONIT 60 MG TABCR,2500012423,CDM,637,RC,904645061,NDC,,,,,,outpatient,facility,60,UN,1.35,1.35,0.11,618.77,,0.79,,,percent of total billed charges,,,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.35,,,percent of total billed charges,,,1.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.22,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,1.35,,,fee schedule,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.95,,,percent of total billed charges,,
ISOSORBIDE MONONIT 60 MG TABCR,2500012423,CDM,637,RC,904645061,NDC,999,EAPG,,,,outpatient,facility,60,UN,1.35,1.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IVERMECTIN 3 MG TAB,2500012469,CDM,637,RC,4279980601,NDC,,,,,,inpatient,facility,3,UN,16.4,16.4,1.31,16.4,,,,,,,,,,,,,,16.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.76,,,percent of total billed charges,,,,,,,,,16.4,,,percent of total billed charges,,,9.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.4,,,percent of total billed charges,,,,,,,,,,,,,,,16.4,,,percent of total billed charges,,,8.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,16.4,,,percent of total billed charges,,,16.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.52,,,percent of total billed charges,,
IVERMECTIN 3 MG TAB,2500012469,CDM,637,RC,4279980601,NDC,,,,,,outpatient,facility,3,UN,16.4,16.4,1.31,618.77,,9.58,,,percent of total billed charges,,,3.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.4,,,percent of total billed charges,,,14.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,14.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,14.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,14.76,,,percent of total billed charges,,,,,,,,,16.4,,,percent of total billed charges,,,11.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.6,,,percent of total billed charges,,,,,,,,,,,,,,,8.86,,,percent of total billed charges,,,8.86,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,16.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.55,,,percent of total billed charges,,,16.4,,,percent of total billed charges,,,16.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.46,,,percent of total billed charges,,,6.21,,,percent of total billed charges,,,8.49,,,percent of total billed charges,,,,,,,,,,,,,,,3.28,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.07,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,16.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.31,,,percent of total billed charges,,,16.4,,,percent of total billed charges,,,16.4,,,percent of total billed charges,,,,,,,,,,,,,,,16.4,,,percent of total billed charges,,,16.4,,,percent of total billed charges,,,,,,,,,16.4,,,fee schedule,,,15.26,,,percent of total billed charges,,,,,,,,,,,,,,,15.26,,,percent of total billed charges,,,15.26,,,percent of total billed charges,,,15.26,,,percent of total billed charges,,,12.3,,,percent of total billed charges,,,16.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.4,,,percent of total billed charges,,,16.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.52,,,percent of total billed charges,,
IVERMECTIN 3 MG TAB,2500012469,CDM,637,RC,4279980601,NDC,999,EAPG,,,,outpatient,facility,3,UN,16.4,16.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETAMINE HCL 200 MG/20 ML INJ,2500012533,CDM,636,RC,J3490,HCPCS,4202311310,NDC,,,,inpatient,facility,20,ML,65.27,65.27,5.22,65.27,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.74,,,percent of total billed charges,,,,,,,,,65.27,,,percent of total billed charges,,,36.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,34.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,65.27,,,percent of total billed charges,,,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.83,,,percent of total billed charges,,
KETAMINE HCL 200 MG/20 ML INJ,2500012533,CDM,636,RC,J3490,HCPCS,4202311310,NDC,,,,outpatient,facility,20,ML,65.27,65.27,1.2,618.77,,38.12,,,percent of total billed charges,,,12.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,23.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,58.74,,,percent of total billed charges,,,,,,,,,65.27,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.13,,,percent of total billed charges,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,65.27,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.03,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.61,,,percent of total billed charges,,,24.72,,,percent of total billed charges,,,33.8,,,percent of total billed charges,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,65.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,65.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.22,,,percent of total billed charges,,,65.27,,,percent of total billed charges,,,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,65.27,,,percent of total billed charges,,,,,,,,,65.27,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,48.95,,,percent of total billed charges,,,65.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,65.27,,,percent of total billed charges,,,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,45.83,,,percent of total billed charges,,
KETAMINE HCL 200 MG/20 ML INJ,2500012533,CDM,636,RC,J3490,HCPCS,4202311310,NDC,435,EAPG,,outpatient,facility,20,ML,65.27,65.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETAMINE HCL 50 MG/ML INJ,2500012534,CDM,636,RC,J3490,HCPCS,143950810,NDC,,,,inpatient,facility,1,ML,16.67,16.67,1.33,16.67,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15,,,percent of total billed charges,,,,,,,,,16.67,,,percent of total billed charges,,,9.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,8.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.71,,,percent of total billed charges,,
KETAMINE HCL 50 MG/ML INJ,2500012534,CDM,636,RC,J3490,HCPCS,143950810,NDC,,,,outpatient,facility,1,ML,16.67,16.67,1.2,618.77,,9.74,,,percent of total billed charges,,,3.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,15,,,percent of total billed charges,,,,,,,,,16.67,,,percent of total billed charges,,,11.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.8,,,percent of total billed charges,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.69,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.67,,,percent of total billed charges,,,6.31,,,percent of total billed charges,,,8.63,,,percent of total billed charges,,,,,,,,,,,,,,,3.33,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.33,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,16.67,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,12.5,,,percent of total billed charges,,,16.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.71,,,percent of total billed charges,,
KETAMINE HCL 50 MG/ML INJ,2500012534,CDM,636,RC,J3490,HCPCS,143950810,NDC,435,EAPG,,outpatient,facility,1,ML,16.67,16.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETAMINE HCL 500 MG/10 ML INJ,2500012535,CDM,636,RC,J3490,HCPCS,143950810,NDC,,,,inpatient,facility,10,ML,21.12,21.12,1.69,21.12,,,,,,,,,,,,,,21.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.01,,,percent of total billed charges,,,,,,,,,21.12,,,percent of total billed charges,,,11.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.12,,,percent of total billed charges,,,,,,,,,,,,,,,21.12,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.83,,,percent of total billed charges,,
KETAMINE HCL 500 MG/10 ML INJ,2500012535,CDM,636,RC,J3490,HCPCS,143950810,NDC,,,,outpatient,facility,10,ML,21.12,21.12,1.2,618.77,,12.33,,,percent of total billed charges,,,4.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,21.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,19.01,,,percent of total billed charges,,,,,,,,,21.12,,,percent of total billed charges,,,14.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.22,,,percent of total billed charges,,,,,,,,,,,,,,,21.12,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,21.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.01,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.05,,,percent of total billed charges,,,8,,,percent of total billed charges,,,10.94,,,percent of total billed charges,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,21.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.69,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,,,,,,,,,,,,,21.12,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,,,,,,,21.12,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,15.84,,,percent of total billed charges,,,21.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,21.12,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,14.83,,,percent of total billed charges,,
KETAMINE HCL 500 MG/10 ML INJ,2500012535,CDM,636,RC,J3490,HCPCS,143950810,NDC,435,EAPG,,outpatient,facility,10,ML,21.12,21.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETAMINE HCL 500 MG/5 ML INJ,2500012536,CDM,636,RC,J3490,HCPCS,409205105,NDC,,,,inpatient,facility,5,ML,27.42,27.42,2.19,27.42,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,,,,,,,27.42,,,percent of total billed charges,,,15.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,14.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,27.42,,,percent of total billed charges,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.25,,,percent of total billed charges,,
KETAMINE HCL 500 MG/5 ML INJ,2500012536,CDM,636,RC,J3490,HCPCS,409205105,NDC,,,,outpatient,facility,5,ML,27.42,27.42,1.2,618.77,,16.01,,,percent of total billed charges,,,5.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,24.68,,,percent of total billed charges,,,,,,,,,27.42,,,percent of total billed charges,,,18.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,27.42,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.3,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.84,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,14.2,,,percent of total billed charges,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,27.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.19,,,percent of total billed charges,,,27.42,,,percent of total billed charges,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,27.42,,,percent of total billed charges,,,,,,,,,27.42,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,20.57,,,percent of total billed charges,,,27.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,27.42,,,percent of total billed charges,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,19.25,,,percent of total billed charges,,
KETAMINE HCL 500 MG/5 ML INJ,2500012536,CDM,636,RC,J3490,HCPCS,409205105,NDC,435,EAPG,,outpatient,facility,5,ML,27.42,27.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOCONAZOLE 2  CR 15 GM,2500012540,CDM,637,RC,168009915,NDC,,,,,,inpatient,facility,15,UN,101.97,101.97,8.16,101.97,,,,,,,,,,,,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.77,,,percent of total billed charges,,,,,,,,,101.97,,,percent of total billed charges,,,56.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,101.97,,,percent of total billed charges,,,53.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.16,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.6,,,percent of total billed charges,,
KETOCONAZOLE 2  CR 15 GM,2500012540,CDM,637,RC,168009915,NDC,,,,,,outpatient,facility,15,UN,101.97,101.97,8.16,618.77,,59.55,,,percent of total billed charges,,,19.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,101.97,,,percent of total billed charges,,,89.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,89.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,89.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,37.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,91.77,,,percent of total billed charges,,,,,,,,,101.97,,,percent of total billed charges,,,69.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.31,,,percent of total billed charges,,,,,,,,,,,,,,,55.06,,,percent of total billed charges,,,55.06,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.17,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.5,,,percent of total billed charges,,,38.63,,,percent of total billed charges,,,52.81,,,percent of total billed charges,,,,,,,,,,,,,,,20.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,37.73,,,percent of total billed charges,,,37.73,,,percent of total billed charges,,,101.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,101.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.16,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,101.97,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,,,,,,,101.97,,,fee schedule,,,94.85,,,percent of total billed charges,,,,,,,,,,,,,,,94.85,,,percent of total billed charges,,,94.85,,,percent of total billed charges,,,94.85,,,percent of total billed charges,,,76.48,,,percent of total billed charges,,,101.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,101.97,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,71.6,,,percent of total billed charges,,
KETOCONAZOLE 2  CR 15 GM,2500012540,CDM,637,RC,168009915,NDC,999,EAPG,,,,outpatient,facility,15,UN,101.97,101.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOCONAZOLE 2  SHAMP 120 ML,2500012541,CDM,637,RC,4580246564,NDC,,,,,,inpatient,facility,120,UN,99.83,99.83,7.99,99.83,,,,,,,,,,,,,,99.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.85,,,percent of total billed charges,,,,,,,,,99.83,,,percent of total billed charges,,,55.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.83,,,percent of total billed charges,,,,,,,,,,,,,,,99.83,,,percent of total billed charges,,,52.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.99,,,percent of total billed charges,,,99.83,,,percent of total billed charges,,,99.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,99.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.1,,,percent of total billed charges,,
KETOCONAZOLE 2  SHAMP 120 ML,2500012541,CDM,637,RC,4580246564,NDC,,,,,,outpatient,facility,120,UN,99.83,99.83,7.99,618.77,,58.3,,,percent of total billed charges,,,19.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,99.83,,,percent of total billed charges,,,87.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,87.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,87.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,99.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,36.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,89.85,,,percent of total billed charges,,,,,,,,,99.83,,,percent of total billed charges,,,67.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.67,,,percent of total billed charges,,,,,,,,,,,,,,,53.91,,,percent of total billed charges,,,53.91,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,99.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.05,,,percent of total billed charges,,,99.83,,,percent of total billed charges,,,99.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.87,,,percent of total billed charges,,,37.82,,,percent of total billed charges,,,51.7,,,percent of total billed charges,,,,,,,,,,,,,,,19.97,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,36.94,,,percent of total billed charges,,,36.94,,,percent of total billed charges,,,99.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,99.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.99,,,percent of total billed charges,,,99.83,,,percent of total billed charges,,,99.83,,,percent of total billed charges,,,,,,,,,,,,,,,99.83,,,percent of total billed charges,,,99.83,,,percent of total billed charges,,,,,,,,,99.83,,,fee schedule,,,92.86,,,percent of total billed charges,,,,,,,,,,,,,,,92.86,,,percent of total billed charges,,,92.86,,,percent of total billed charges,,,92.86,,,percent of total billed charges,,,74.87,,,percent of total billed charges,,,99.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,99.83,,,percent of total billed charges,,,99.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,70.1,,,percent of total billed charges,,
KETOCONAZOLE 2  SHAMP 120 ML,2500012541,CDM,637,RC,4580246564,NDC,999,EAPG,,,,outpatient,facility,120,UN,99.83,99.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOROLAC 0.5  OPH 5 ML,2500012550,CDM,637,RC,6050510031,NDC,,,,,,inpatient,facility,5,UN,352.67,352.67,28.21,352.67,,,,,,,,,,,,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,317.4,,,percent of total billed charges,,,,,,,,,352.67,,,percent of total billed charges,,,195.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,321.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,352.67,,,percent of total billed charges,,,183.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.21,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247.64,,,percent of total billed charges,,
KETOROLAC 0.5  OPH 5 ML,2500012550,CDM,637,RC,6050510031,NDC,,,,,,outpatient,facility,5,UN,352.67,352.67,28.21,618.77,,205.96,,,percent of total billed charges,,,68.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,352.67,,,percent of total billed charges,,,310.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,310.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,310.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,129.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,317.4,,,percent of total billed charges,,,,,,,,,352.67,,,percent of total billed charges,,,238.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270.85,,,percent of total billed charges,,,,,,,,,,,,,,,190.44,,,percent of total billed charges,,,190.44,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,183.88,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.03,,,percent of total billed charges,,,133.59,,,percent of total billed charges,,,182.65,,,percent of total billed charges,,,,,,,,,,,,,,,70.53,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,130.49,,,percent of total billed charges,,,130.49,,,percent of total billed charges,,,352.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,352.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.21,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,352.67,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,,,,,,,352.67,,,fee schedule,,,328.05,,,percent of total billed charges,,,,,,,,,,,,,,,328.05,,,percent of total billed charges,,,328.05,,,percent of total billed charges,,,328.05,,,percent of total billed charges,,,264.5,,,percent of total billed charges,,,352.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,352.67,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,247.64,,,percent of total billed charges,,
KETOROLAC 0.5  OPH 5 ML,2500012550,CDM,637,RC,6050510031,NDC,999,EAPG,,,,outpatient,facility,5,UN,352.67,352.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOROLAC 10 MG TAB,2500012551,CDM,637,RC,93031401,NDC,,,,,,inpatient,facility,10,UN,7.13,7.13,0.57,7.13,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.42,,,percent of total billed charges,,,,,,,,,7.13,,,percent of total billed charges,,,3.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,3.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,
KETOROLAC 10 MG TAB,2500012551,CDM,637,RC,93031401,NDC,,,,,,outpatient,facility,10,UN,7.13,7.13,0.57,618.77,,4.16,,,percent of total billed charges,,,1.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.13,,,percent of total billed charges,,,6.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.42,,,percent of total billed charges,,,,,,,,,7.13,,,percent of total billed charges,,,4.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,3.85,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.72,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.42,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,3.69,,,percent of total billed charges,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,7.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.57,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,7.13,,,fee schedule,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,5.35,,,percent of total billed charges,,,7.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.13,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.01,,,percent of total billed charges,,
KETOROLAC 10 MG TAB,2500012551,CDM,637,RC,93031401,NDC,999,EAPG,,,,outpatient,facility,10,UN,7.13,7.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LABETALOL HCL 100 MG TAB,2500012560,CDM,637,RC,6838279801,NDC,,,,,,inpatient,facility,100,UN,2.21,2.21,0.18,2.21,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,
LABETALOL HCL 100 MG TAB,2500012560,CDM,637,RC,6838279801,NDC,,,,,,outpatient,facility,100,UN,2.21,2.21,0.18,618.77,,1.29,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.21,,,percent of total billed charges,,,1.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.99,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,2.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,2.21,,,fee schedule,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,2.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.55,,,percent of total billed charges,,
LABETALOL HCL 100 MG TAB,2500012560,CDM,637,RC,6838279801,NDC,999,EAPG,,,,outpatient,facility,100,UN,2.21,2.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LABETALOL HCL 20 MG/4 ML SYR,2500012562,CDM,250,RC,J3490,HCPCS,409233934,NDC,,,,inpatient,facility,4,UN,29.96,29.96,2.4,29.96,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.96,,,percent of total billed charges,,,,,,,,,29.96,,,percent of total billed charges,,,16.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,15.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.04,,,percent of total billed charges,,
LABETALOL HCL 20 MG/4 ML SYR,2500012562,CDM,250,RC,J3490,HCPCS,409233934,NDC,,,,outpatient,facility,4,UN,29.96,29.96,1.2,618.77,,17.5,,,percent of total billed charges,,,5.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,29.96,,,percent of total billed charges,,,26.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,26.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,26.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26.96,,,percent of total billed charges,,,,,,,,,29.96,,,percent of total billed charges,,,20.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.01,,,percent of total billed charges,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.62,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.77,,,percent of total billed charges,,,11.35,,,percent of total billed charges,,,15.52,,,percent of total billed charges,,,,,,,,,,,,,,,5.99,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,29.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.4,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,,,,,,,29.96,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,22.47,,,percent of total billed charges,,,29.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,29.96,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,21.04,,,percent of total billed charges,,
LABETALOL HCL 20 MG/4 ML SYR,2500012562,CDM,250,RC,J3490,HCPCS,409233934,NDC,435,EAPG,,outpatient,facility,4,UN,29.96,29.96,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LABETALOL HCL 200 MG TAB,2500012563,CDM,637,RC,6838279905,NDC,,,,,,inpatient,facility,200,UN,3.56,3.56,0.28,3.56,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,
LABETALOL HCL 200 MG TAB,2500012563,CDM,637,RC,6838279905,NDC,,,,,,outpatient,facility,200,UN,3.56,3.56,0.28,618.77,,2.08,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.56,,,percent of total billed charges,,,3.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.2,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,3.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,3.56,,,fee schedule,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,3.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.5,,,percent of total billed charges,,
LABETALOL HCL 200 MG TAB,2500012563,CDM,637,RC,6838279905,NDC,999,EAPG,,,,outpatient,facility,200,UN,3.56,3.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACTIC ACID 12  LOT 225 GM,2500012582,CDM,637,RC,904598426,NDC,,,,,,inpatient,facility,225,UN,5.78,5.78,0.46,5.78,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.2,,,percent of total billed charges,,,,,,,,,5.78,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,
LACTIC ACID 12  LOT 225 GM,2500012582,CDM,637,RC,904598426,NDC,,,,,,outpatient,facility,225,UN,5.78,5.78,0.46,618.77,,3.38,,,percent of total billed charges,,,1.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.78,,,percent of total billed charges,,,5.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.2,,,percent of total billed charges,,,,,,,,,5.78,,,percent of total billed charges,,,3.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.44,,,percent of total billed charges,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,3.12,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.39,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,5.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,5.78,,,fee schedule,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,4.33,,,percent of total billed charges,,,5.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.06,,,percent of total billed charges,,
LACTIC ACID 12  LOT 225 GM,2500012582,CDM,637,RC,904598426,NDC,999,EAPG,,,,outpatient,facility,225,UN,5.78,5.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACTOBACILL ACIDOPH/BULGAR PKT,2500012590,CDM,637,RC,6498014612,NDC,,,,,,inpatient,facility,1,UN,3.05,3.05,0.24,3.05,,,,,,,,,,,,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,,,,,,,3.05,,,percent of total billed charges,,,1.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,3.05,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,
LACTOBACILL ACIDOPH/BULGAR PKT,2500012590,CDM,637,RC,6498014612,NDC,,,,,,outpatient,facility,1,UN,3.05,3.05,0.24,618.77,,1.78,,,percent of total billed charges,,,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.05,,,percent of total billed charges,,,2.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.75,,,percent of total billed charges,,,,,,,,,3.05,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.13,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,3.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,3.05,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,3.05,,,fee schedule,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,2.29,,,percent of total billed charges,,,3.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.05,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.14,,,percent of total billed charges,,
LACTOBACILL ACIDOPH/BULGAR PKT,2500012590,CDM,637,RC,6498014612,NDC,999,EAPG,,,,outpatient,facility,1,UN,3.05,3.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACTOBACILLUS ACIDOPHILUS TAB,2500012595,CDM,637,RC,8113105855,NDC,,,,,,inpatient,facility,1,UN,1.68,1.68,0.13,1.68,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
LACTOBACILLUS ACIDOPHILUS TAB,2500012595,CDM,637,RC,8113105855,NDC,,,,,,outpatient,facility,1,UN,1.68,1.68,0.13,618.77,,0.98,,,percent of total billed charges,,,0.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.68,,,percent of total billed charges,,,1.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.51,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,1.68,,,fee schedule,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.18,,,percent of total billed charges,,
LACTOBACILLUS ACIDOPHILUS TAB,2500012595,CDM,637,RC,8113105855,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.68,1.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACTULOSE 20 GM/30 ML UDC,2500012616,CDM,637,RC,121115400,NDC,,,,,,inpatient,facility,30,UN,6,6,0.48,6,,,,,,,,,,,,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,,,,,,,,6,,,percent of total billed charges,,,3.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,6,,,percent of total billed charges,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,
LACTULOSE 20 GM/30 ML UDC,2500012616,CDM,637,RC,121115400,NDC,,,,,,outpatient,facility,30,UN,6,6,0.48,618.77,,3.5,,,percent of total billed charges,,,1.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6,,,percent of total billed charges,,,5.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.4,,,percent of total billed charges,,,,,,,,,6,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.61,,,percent of total billed charges,,,,,,,,,,,,,,,3.24,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,6,,,percent of total billed charges,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.56,,,percent of total billed charges,,,2.27,,,percent of total billed charges,,,3.11,,,percent of total billed charges,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.22,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.48,,,percent of total billed charges,,,6,,,percent of total billed charges,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,6,,,percent of total billed charges,,,,,,,,,6,,,fee schedule,,,5.58,,,percent of total billed charges,,,,,,,,,,,,,,,5.58,,,percent of total billed charges,,,5.58,,,percent of total billed charges,,,5.58,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6,,,percent of total billed charges,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.21,,,percent of total billed charges,,
LACTULOSE 20 GM/30 ML UDC,2500012616,CDM,637,RC,121115400,NDC,999,EAPG,,,,outpatient,facility,30,UN,6,6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LAMIVUDINE 150 MG/15 ML UDC,2500012620,CDM,637,RC,5723727424,NDC,,,,,,inpatient,facility,15,UN,24.68,24.68,1.97,24.68,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.21,,,percent of total billed charges,,,,,,,,,24.68,,,percent of total billed charges,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.33,,,percent of total billed charges,,
LAMIVUDINE 150 MG/15 ML UDC,2500012620,CDM,637,RC,5723727424,NDC,,,,,,outpatient,facility,15,UN,24.68,24.68,1.97,618.77,,14.41,,,percent of total billed charges,,,4.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,24.68,,,percent of total billed charges,,,21.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,21.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,21.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22.21,,,percent of total billed charges,,,,,,,,,24.68,,,percent of total billed charges,,,16.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.95,,,percent of total billed charges,,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.76,,,percent of total billed charges,,,9.35,,,percent of total billed charges,,,12.78,,,percent of total billed charges,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,9.13,,,percent of total billed charges,,,9.13,,,percent of total billed charges,,,24.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.97,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,24.68,,,fee schedule,,,22.96,,,percent of total billed charges,,,,,,,,,,,,,,,22.96,,,percent of total billed charges,,,22.96,,,percent of total billed charges,,,22.96,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,24.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,24.68,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.33,,,percent of total billed charges,,
LAMIVUDINE 150 MG/15 ML UDC,2500012620,CDM,637,RC,5723727424,NDC,999,EAPG,,,,outpatient,facility,15,UN,24.68,24.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LAMOTRIGINE 100 MG TAB,2500012630,CDM,637,RC,904700861,NDC,,,,,,inpatient,facility,100,UN,0.46,0.46,0.04,0.46,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,
LAMOTRIGINE 100 MG TAB,2500012630,CDM,637,RC,904700861,NDC,,,,,,outpatient,facility,100,UN,0.46,0.46,0.04,618.77,,0.27,,,percent of total billed charges,,,0.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,0.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.41,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.17,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.46,,,fee schedule,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,0.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.32,,,percent of total billed charges,,
LAMOTRIGINE 100 MG TAB,2500012630,CDM,637,RC,904700861,NDC,999,EAPG,,,,outpatient,facility,100,UN,0.46,0.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LAMOTRIGINE 25 MG TAB,2500012632,CDM,637,RC,6586222701,NDC,,,,,,inpatient,facility,25,UN,13.72,13.72,1.1,13.72,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.35,,,percent of total billed charges,,,,,,,,,13.72,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,7.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.63,,,percent of total billed charges,,
LAMOTRIGINE 25 MG TAB,2500012632,CDM,637,RC,6586222701,NDC,,,,,,outpatient,facility,25,UN,13.72,13.72,1.1,618.77,,8.01,,,percent of total billed charges,,,2.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.72,,,percent of total billed charges,,,12.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.35,,,percent of total billed charges,,,,,,,,,13.72,,,percent of total billed charges,,,9.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.54,,,percent of total billed charges,,,,,,,,,,,,,,,7.41,,,percent of total billed charges,,,7.41,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.15,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.43,,,percent of total billed charges,,,5.2,,,percent of total billed charges,,,7.11,,,percent of total billed charges,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.08,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,13.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,13.72,,,fee schedule,,,12.76,,,percent of total billed charges,,,,,,,,,,,,,,,12.76,,,percent of total billed charges,,,12.76,,,percent of total billed charges,,,12.76,,,percent of total billed charges,,,10.29,,,percent of total billed charges,,,13.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.63,,,percent of total billed charges,,
LAMOTRIGINE 25 MG TAB,2500012632,CDM,637,RC,6586222701,NDC,999,EAPG,,,,outpatient,facility,25,UN,13.72,13.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LANOLIN MODIFIED 7 GR OINT,2500012644,CDM,637,RC,9277159614,NDC,,,,,,inpatient,facility,7,UN,1.52,1.52,0.12,1.52,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,
LANOLIN MODIFIED 7 GR OINT,2500012644,CDM,637,RC,9277159614,NDC,,,,,,outpatient,facility,7,UN,1.52,1.52,0.12,618.77,,0.89,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.52,,,percent of total billed charges,,,1.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.37,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,1.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,1.52,,,fee schedule,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,1.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.07,,,percent of total billed charges,,
LANOLIN MODIFIED 7 GR OINT,2500012644,CDM,637,RC,9277159614,NDC,999,EAPG,,,,outpatient,facility,7,UN,1.52,1.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LATANOPROST 0.005  OPH 2.5ML,2500012660,CDM,637,RC,6131454701,NDC,,,,,,inpatient,facility,2.5,UN,313.5,313.5,25.08,313.5,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.15,,,percent of total billed charges,,,,,,,,,313.5,,,percent of total billed charges,,,173.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,286.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,163.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.08,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.14,,,percent of total billed charges,,
LATANOPROST 0.005  OPH 2.5ML,2500012660,CDM,637,RC,6131454701,NDC,,,,,,outpatient,facility,2.5,UN,313.5,313.5,25.08,618.77,,183.08,,,percent of total billed charges,,,61.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,313.5,,,percent of total billed charges,,,276.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,276.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,276.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,114.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,282.15,,,percent of total billed charges,,,,,,,,,313.5,,,percent of total billed charges,,,212.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.77,,,percent of total billed charges,,,,,,,,,,,,,,,169.29,,,percent of total billed charges,,,169.29,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,163.46,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.26,,,percent of total billed charges,,,118.75,,,percent of total billed charges,,,162.36,,,percent of total billed charges,,,,,,,,,,,,,,,62.7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,116,,,percent of total billed charges,,,116,,,percent of total billed charges,,,313.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,313.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.08,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,313.5,,,fee schedule,,,291.62,,,percent of total billed charges,,,,,,,,,,,,,,,291.62,,,percent of total billed charges,,,291.62,,,percent of total billed charges,,,291.62,,,percent of total billed charges,,,235.13,,,percent of total billed charges,,,313.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,220.14,,,percent of total billed charges,,
LATANOPROST 0.005  OPH 2.5ML,2500012660,CDM,637,RC,6131454701,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,313.5,313.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 4  W/TEGADERM KIT,2500012675,CDM,637,RC,7632963005,NDC,,,,,,inpatient,facility,4,UN,99.66,99.66,7.97,99.66,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.69,,,percent of total billed charges,,,,,,,,,99.66,,,percent of total billed charges,,,55.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,51.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.97,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.98,,,percent of total billed charges,,
LIDOCAINE 4  W/TEGADERM KIT,2500012675,CDM,637,RC,7632963005,NDC,,,,,,outpatient,facility,4,UN,99.66,99.66,7.97,618.77,,58.2,,,percent of total billed charges,,,19.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,99.66,,,percent of total billed charges,,,87.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,87.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,87.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,36.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,89.69,,,percent of total billed charges,,,,,,,,,99.66,,,percent of total billed charges,,,67.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.54,,,percent of total billed charges,,,,,,,,,,,,,,,53.82,,,percent of total billed charges,,,53.82,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.96,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.74,,,percent of total billed charges,,,37.75,,,percent of total billed charges,,,51.61,,,percent of total billed charges,,,,,,,,,,,,,,,19.93,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,36.87,,,percent of total billed charges,,,36.87,,,percent of total billed charges,,,99.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,99.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.97,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,,,,,,,99.66,,,fee schedule,,,92.7,,,percent of total billed charges,,,,,,,,,,,,,,,92.7,,,percent of total billed charges,,,92.7,,,percent of total billed charges,,,92.7,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,99.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,99.66,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,69.98,,,percent of total billed charges,,
LIDOCAINE 4  W/TEGADERM KIT,2500012675,CDM,637,RC,7632963005,NDC,999,EAPG,,,,outpatient,facility,4,UN,99.66,99.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEUCOVORIN CALCIUM 5 MG TAB,2500012682,CDM,637,RC,54449625,NDC,,,,,,inpatient,facility,5,UN,6.7,6.7,0.54,6.7,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.03,,,percent of total billed charges,,,,,,,,,6.7,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,3.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.7,,,percent of total billed charges,,
LEUCOVORIN CALCIUM 5 MG TAB,2500012682,CDM,637,RC,54449625,NDC,,,,,,outpatient,facility,5,UN,6.7,6.7,0.54,618.77,,3.91,,,percent of total billed charges,,,1.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.7,,,percent of total billed charges,,,5.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.03,,,percent of total billed charges,,,,,,,,,6.7,,,percent of total billed charges,,,4.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,3.62,,,percent of total billed charges,,,3.62,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.09,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,6.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.54,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,,,,,,,6.7,,,fee schedule,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,6.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.7,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.7,,,percent of total billed charges,,
LEUCOVORIN CALCIUM 5 MG TAB,2500012682,CDM,637,RC,54449625,NDC,999,EAPG,,,,outpatient,facility,5,UN,6.7,6.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVALBUTEROL NEBU .625 MG/3ML,2500012692,CDM,637,RC,J7614,HCPCS,7620480001,NDC,,,,inpatient,facility,3,UN,6.6,6.6,0.53,6.6,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,3.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,
LEVALBUTEROL NEBU .625 MG/3ML,2500012692,CDM,637,RC,J7614,HCPCS,7620480001,NDC,,,,outpatient,facility,3,UN,6.6,6.6,0.03,618.77,,3.85,,,percent of total billed charges,,,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.6,,,percent of total billed charges,,,0.06,,,fee schedule,,,0.06,,,fee schedule,,,,,,,,,0.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.94,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,4.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,fee schedule,,,0.05,,,fee schedule,,,,,,,,,618.77,,,per diem,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,3.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.11,,,fee schedule,,,0.05,,,fee schedule,,,6.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.53,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,0.08,,,fee schedule,,,0.05,,,fee schedule,,,,,,,,,,,,,,,0.05,,,fee schedule,,,0.06,,,fee schedule,,,0.03,,,fee schedule,,,0.06,,,fee schedule,,,6.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.63,,,percent of total billed charges,,
LEVALBUTEROL NEBU .625 MG/3ML,2500012692,CDM,637,RC,J7614,HCPCS,7620480001,NDC,496,EAPG,,outpatient,facility,3,UN,6.6,6.6,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVALBUTEROL NEBU 1.25 MG/3ML,2500012693,CDM,637,RC,J7614,HCPCS,7620490001,NDC,,,,inpatient,facility,3,UN,6.6,6.6,0.53,6.6,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,3.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,
LEVALBUTEROL NEBU 1.25 MG/3ML,2500012693,CDM,637,RC,J7614,HCPCS,7620490001,NDC,,,,outpatient,facility,3,UN,6.6,6.6,0.03,618.77,,3.85,,,percent of total billed charges,,,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.6,,,percent of total billed charges,,,0.06,,,fee schedule,,,0.06,,,fee schedule,,,,,,,,,0.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.94,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,4.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,fee schedule,,,0.05,,,fee schedule,,,,,,,,,618.77,,,per diem,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,3.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.11,,,fee schedule,,,0.05,,,fee schedule,,,6.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.53,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,0.08,,,fee schedule,,,0.05,,,fee schedule,,,,,,,,,,,,,,,0.05,,,fee schedule,,,0.06,,,fee schedule,,,0.03,,,fee schedule,,,0.06,,,fee schedule,,,6.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.63,,,percent of total billed charges,,
LEVALBUTEROL NEBU 1.25 MG/3ML,2500012693,CDM,637,RC,J7614,HCPCS,7620490001,NDC,496,EAPG,,outpatient,facility,3,UN,6.6,6.6,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVETIRACETAM 500 MG TAB,2500012710,CDM,637,RC,904712461,NDC,,,,,,inpatient,facility,500,UN,0.69,0.69,0.06,0.69,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,
LEVETIRACETAM 500 MG TAB,2500012710,CDM,637,RC,904712461,NDC,,,,,,outpatient,facility,500,UN,0.69,0.69,0.06,618.77,,0.4,,,percent of total billed charges,,,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.69,,,percent of total billed charges,,,0.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.62,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.69,,,fee schedule,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.48,,,percent of total billed charges,,
LEVETIRACETAM 500 MG TAB,2500012710,CDM,637,RC,904712461,NDC,999,EAPG,,,,outpatient,facility,500,UN,0.69,0.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVETIRACETAM 250 MG TAB,2500012712,CDM,637,RC,904712361,NDC,,,,,,inpatient,facility,250,UN,0.59,0.59,0.05,0.59,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,
LEVETIRACETAM 250 MG TAB,2500012712,CDM,637,RC,904712361,NDC,,,,,,outpatient,facility,250,UN,0.59,0.59,0.05,618.77,,0.34,,,percent of total billed charges,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,0.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.53,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.22,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,0.59,,,fee schedule,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,0.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.41,,,percent of total billed charges,,
LEVETIRACETAM 250 MG TAB,2500012712,CDM,637,RC,904712361,NDC,999,EAPG,,,,outpatient,facility,250,UN,0.59,0.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVETIRACETAM INJ 500 MG,2500012714,CDM,636,RC,J1953,HCPCS,5515017705,NDC,,,,inpatient,facility,5,ML,49.5,49.5,3.96,49.5,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.55,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,27.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,25.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.76,,,percent of total billed charges,,
LEVETIRACETAM INJ 500 MG,2500012714,CDM,636,RC,J1953,HCPCS,5515017705,NDC,,,,outpatient,facility,5,ML,49.5,49.5,0.06,618.77,,28.91,,,percent of total billed charges,,,9.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,49.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,18.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,44.55,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,33.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.81,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.62,,,percent of total billed charges,,,18.75,,,percent of total billed charges,,,25.64,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,49.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,49.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.96,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,49.5,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.06,,,fee schedule,,,49.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,34.76,,,percent of total billed charges,,
LEVETIRACETAM INJ 500 MG,2500012714,CDM,636,RC,J1953,HCPCS,5515017705,NDC,999,EAPG,,outpatient,facility,5,ML,49.5,49.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVETRCTM 500 MG/5ML UDC ORAL,2500012716,CDM,250,RC,121479940,NDC,,,,,,inpatient,facility,5,ML,30.85,30.85,2.47,30.85,,,,,,,,,,,,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.77,,,percent of total billed charges,,,,,,,,,30.85,,,percent of total billed charges,,,17.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,30.85,,,percent of total billed charges,,,16.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.66,,,percent of total billed charges,,
LEVETRCTM 500 MG/5ML UDC ORAL,2500012716,CDM,250,RC,121479940,NDC,,,,,,outpatient,facility,5,ML,30.85,30.85,2.47,618.77,,18.02,,,percent of total billed charges,,,6.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,30.85,,,percent of total billed charges,,,27.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,27.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,27.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,27.77,,,percent of total billed charges,,,,,,,,,30.85,,,percent of total billed charges,,,20.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.09,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.45,,,percent of total billed charges,,,11.69,,,percent of total billed charges,,,15.98,,,percent of total billed charges,,,,,,,,,,,,,,,6.17,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,12.34,,,percent of total billed charges,,,12.34,,,percent of total billed charges,,,30.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.47,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,30.85,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,,,,,,,30.85,,,fee schedule,,,12.34,,,percent of total billed charges,,,,,,,,,,,,,,,12.34,,,percent of total billed charges,,,12.34,,,percent of total billed charges,,,12.34,,,percent of total billed charges,,,23.14,,,percent of total billed charges,,,30.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,30.85,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,21.66,,,percent of total billed charges,,
LEVETRCTM 500 MG/5ML UDC ORAL,2500012716,CDM,250,RC,121479940,NDC,999,EAPG,,,,outpatient,facility,5,ML,30.85,30.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVETIRACTM 1000 MG/100 ML PMX,2500012718,CDM,636,RC,J1953,HCPCS,5515024747,NDC,,,,inpatient,facility,100,ML,178.2,178.2,14.26,178.2,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.38,,,percent of total billed charges,,,,,,,,,178.2,,,percent of total billed charges,,,98.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,92.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.13,,,percent of total billed charges,,
LEVETIRACTM 1000 MG/100 ML PMX,2500012718,CDM,636,RC,J1953,HCPCS,5515024747,NDC,,,,outpatient,facility,100,ML,178.2,178.2,0.06,618.77,,104.07,,,percent of total billed charges,,,34.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,178.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,65.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,160.38,,,percent of total billed charges,,,,,,,,,178.2,,,percent of total billed charges,,,120.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,92.91,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.43,,,percent of total billed charges,,,67.5,,,percent of total billed charges,,,92.29,,,percent of total billed charges,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,178.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,178.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.26,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,,,,,,,178.2,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.06,,,fee schedule,,,178.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,178.2,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,125.13,,,percent of total billed charges,,
LEVETIRACTM 1000 MG/100 ML PMX,2500012718,CDM,636,RC,J1953,HCPCS,5515024747,NDC,999,EAPG,,outpatient,facility,100,ML,178.2,178.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVETIRACTM 1500 MG/100 ML PMX,2500012719,CDM,636,RC,J1953,HCPCS,5515024847,NDC,,,,inpatient,facility,100,ML,237.6,237.6,19.01,237.6,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.84,,,percent of total billed charges,,,,,,,,,237.6,,,percent of total billed charges,,,131.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,216.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,123.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.01,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.84,,,percent of total billed charges,,
LEVETIRACTM 1500 MG/100 ML PMX,2500012719,CDM,636,RC,J1953,HCPCS,5515024847,NDC,,,,outpatient,facility,100,ML,237.6,237.6,0.06,618.77,,138.76,,,percent of total billed charges,,,46.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,237.6,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,86.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,213.84,,,percent of total billed charges,,,,,,,,,237.6,,,percent of total billed charges,,,160.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.88,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.58,,,percent of total billed charges,,,90,,,percent of total billed charges,,,123.05,,,percent of total billed charges,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,237.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,237.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.01,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,,,,,,,237.6,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.06,,,fee schedule,,,237.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,237.6,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,166.84,,,percent of total billed charges,,
LEVETIRACTM 1500 MG/100 ML PMX,2500012719,CDM,636,RC,J1953,HCPCS,5515024847,NDC,999,EAPG,,outpatient,facility,100,ML,237.6,237.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOFLOXACIN 250 MG TAB,2500012760,CDM,637,RC,904635161,NDC,,,,,,inpatient,facility,250,UN,0.72,0.72,0.06,0.72,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,0.72,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,
LEVOFLOXACIN 250 MG TAB,2500012760,CDM,637,RC,904635161,NDC,,,,,,outpatient,facility,250,UN,0.72,0.72,0.06,618.77,,0.42,,,percent of total billed charges,,,0.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.72,,,percent of total billed charges,,,0.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.65,,,percent of total billed charges,,,,,,,,,0.72,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,0.72,,,fee schedule,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,0.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.72,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.51,,,percent of total billed charges,,
LEVOFLOXACIN 250 MG TAB,2500012760,CDM,637,RC,904635161,NDC,999,EAPG,,,,outpatient,facility,250,UN,0.72,0.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOFLOXACIN 500 MG TAB,2500012762,CDM,637,RC,904635261,NDC,,,,,,inpatient,facility,500,UN,0.79,0.79,0.06,0.79,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,
LEVOFLOXACIN 500 MG TAB,2500012762,CDM,637,RC,904635261,NDC,,,,,,outpatient,facility,500,UN,0.79,0.79,0.06,618.77,,0.46,,,percent of total billed charges,,,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.71,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,0.79,,,fee schedule,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.55,,,percent of total billed charges,,
LEVOFLOXACIN 500 MG TAB,2500012762,CDM,637,RC,904635261,NDC,999,EAPG,,,,outpatient,facility,500,UN,0.79,0.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOFLOXACIN 750 MG TAB,2500012763,CDM,637,RC,904635361,NDC,,,,,,inpatient,facility,750,UN,1.45,1.45,0.12,1.45,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,
LEVOFLOXACIN 750 MG TAB,2500012763,CDM,637,RC,904635361,NDC,,,,,,outpatient,facility,750,UN,1.45,1.45,0.12,618.77,,0.85,,,percent of total billed charges,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.45,,,percent of total billed charges,,,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.3,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.54,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,1.45,,,fee schedule,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.02,,,percent of total billed charges,,
LEVOFLOXACIN 750 MG TAB,2500012763,CDM,637,RC,904635361,NDC,999,EAPG,,,,outpatient,facility,750,UN,1.45,1.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.025 MG TAB,2500012780,CDM,637,RC,6068745301,NDC,,,,,,inpatient,facility,25,UN,1.85,1.85,0.15,1.85,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,
LEVOTHYROXINE 0.025 MG TAB,2500012780,CDM,637,RC,6068745301,NDC,,,,,,outpatient,facility,25,UN,1.85,1.85,0.15,618.77,,1.08,,,percent of total billed charges,,,0.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.85,,,percent of total billed charges,,,1.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.67,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,1.85,,,fee schedule,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,1.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.3,,,percent of total billed charges,,
LEVOTHYROXINE 0.025 MG TAB,2500012780,CDM,637,RC,6068745301,NDC,999,EAPG,,,,outpatient,facility,25,UN,1.85,1.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.05 MG TAB,2500012781,CDM,637,RC,904695061,NDC,,,,,,inpatient,facility,50,UN,1.55,1.55,0.12,1.55,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,
LEVOTHYROXINE 0.05 MG TAB,2500012781,CDM,637,RC,904695061,NDC,,,,,,outpatient,facility,50,UN,1.55,1.55,0.12,618.77,,0.91,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.55,,,percent of total billed charges,,,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.4,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.57,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,1.55,,,fee schedule,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.09,,,percent of total billed charges,,
LEVOTHYROXINE 0.05 MG TAB,2500012781,CDM,637,RC,904695061,NDC,999,EAPG,,,,outpatient,facility,50,UN,1.55,1.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.075 MG TAB,2500012782,CDM,637,RC,904695161,NDC,,,,,,inpatient,facility,75,UN,1.88,1.88,0.15,1.88,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,
LEVOTHYROXINE 0.075 MG TAB,2500012782,CDM,637,RC,904695161,NDC,,,,,,outpatient,facility,75,UN,1.88,1.88,0.15,618.77,,1.1,,,percent of total billed charges,,,0.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.88,,,percent of total billed charges,,,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.69,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.7,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,1.88,,,fee schedule,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.32,,,percent of total billed charges,,
LEVOTHYROXINE 0.075 MG TAB,2500012782,CDM,637,RC,904695161,NDC,999,EAPG,,,,outpatient,facility,75,UN,1.88,1.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.088 MG TAB,2500012783,CDM,637,RC,6818096803,NDC,,,,,,inpatient,facility,88,UN,1.85,1.85,0.15,1.85,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,
LEVOTHYROXINE 0.088 MG TAB,2500012783,CDM,637,RC,6818096803,NDC,,,,,,outpatient,facility,88,UN,1.85,1.85,0.15,618.77,,1.08,,,percent of total billed charges,,,0.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.85,,,percent of total billed charges,,,1.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.67,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,1.85,,,fee schedule,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,1.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.3,,,percent of total billed charges,,
LEVOTHYROXINE 0.088 MG TAB,2500012783,CDM,637,RC,6818096803,NDC,999,EAPG,,,,outpatient,facility,88,UN,1.85,1.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.1 MG TAB,2500012784,CDM,637,RC,904695361,NDC,,,,,,inpatient,facility,100,UN,1.94,1.94,0.16,1.94,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,
LEVOTHYROXINE 0.1 MG TAB,2500012784,CDM,637,RC,904695361,NDC,,,,,,outpatient,facility,100,UN,1.94,1.94,0.16,618.77,,1.13,,,percent of total billed charges,,,0.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.94,,,percent of total billed charges,,,1.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.75,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.72,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,1.94,,,fee schedule,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,1.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.36,,,percent of total billed charges,,
LEVOTHYROXINE 0.1 MG TAB,2500012784,CDM,637,RC,904695361,NDC,999,EAPG,,,,outpatient,facility,100,UN,1.94,1.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.112 MG TAB,2500012785,CDM,637,RC,6818097003,NDC,,,,,,inpatient,facility,112,UN,2.14,2.14,0.17,2.14,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,,,,,2.14,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,
LEVOTHYROXINE 0.112 MG TAB,2500012785,CDM,637,RC,6818097003,NDC,,,,,,outpatient,facility,112,UN,2.14,2.14,0.17,618.77,,1.25,,,percent of total billed charges,,,0.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.14,,,percent of total billed charges,,,1.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.93,,,percent of total billed charges,,,,,,,,,2.14,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,2.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,2.14,,,fee schedule,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,2.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.5,,,percent of total billed charges,,
LEVOTHYROXINE 0.112 MG TAB,2500012785,CDM,637,RC,6818097003,NDC,999,EAPG,,,,outpatient,facility,112,UN,2.14,2.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.125 MG TAB,2500012786,CDM,637,RC,6818097103,NDC,,,,,,inpatient,facility,125,UN,2.18,2.18,0.17,2.18,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,
LEVOTHYROXINE 0.125 MG TAB,2500012786,CDM,637,RC,6818097103,NDC,,,,,,outpatient,facility,125,UN,2.18,2.18,0.17,618.77,,1.27,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.18,,,percent of total billed charges,,,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.96,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.81,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,2.18,,,fee schedule,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,2.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.53,,,percent of total billed charges,,
LEVOTHYROXINE 0.125 MG TAB,2500012786,CDM,637,RC,6818097103,NDC,999,EAPG,,,,outpatient,facility,125,UN,2.18,2.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.15 MG TAB,2500012787,CDM,637,RC,6818097303,NDC,,,,,,inpatient,facility,150,UN,2.24,2.24,0.18,2.24,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,
LEVOTHYROXINE 0.15 MG TAB,2500012787,CDM,637,RC,6818097303,NDC,,,,,,outpatient,facility,150,UN,2.24,2.24,0.18,618.77,,1.31,,,percent of total billed charges,,,0.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.24,,,percent of total billed charges,,,1.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.02,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,2.24,,,fee schedule,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,2.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.57,,,percent of total billed charges,,
LEVOTHYROXINE 0.15 MG TAB,2500012787,CDM,637,RC,6818097303,NDC,999,EAPG,,,,outpatient,facility,150,UN,2.24,2.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 100 MCG INJ,2500012794,CDM,636,RC,J0650,HCPCS,4202320101,NDC,,,,inpatient,facility,100,UN,348.41,348.41,27.87,348.41,,,,,,,,,,,,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.57,,,percent of total billed charges,,,,,,,,,348.41,,,percent of total billed charges,,,192.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,317.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,348.41,,,percent of total billed charges,,,181.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.87,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.65,,,percent of total billed charges,,
LEVOTHYROXINE 100 MCG INJ,2500012794,CDM,636,RC,J0650,HCPCS,4202320101,NDC,,,,outpatient,facility,100,UN,348.41,348.41,13.71,618.77,,203.47,,,percent of total billed charges,,,67.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,348.41,,,percent of total billed charges,,,14.23,,,fee schedule,,,13.71,,,fee schedule,,,,,,,,,13.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,127.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,313.57,,,percent of total billed charges,,,,,,,,,348.41,,,percent of total billed charges,,,235.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.58,,,percent of total billed charges,,,,,,,,,,,,,,,188.14,,,percent of total billed charges,,,188.14,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,181.66,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.79,,,percent of total billed charges,,,131.98,,,percent of total billed charges,,,180.44,,,percent of total billed charges,,,,,,,,,,,,,,,69.68,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,128.91,,,percent of total billed charges,,,128.91,,,percent of total billed charges,,,348.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,348.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.87,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,348.41,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,,,,,,,348.41,,,fee schedule,,,324.09,,,percent of total billed charges,,,,,,,,,,,,,,,324.09,,,percent of total billed charges,,,324.09,,,percent of total billed charges,,,324.09,,,percent of total billed charges,,,261.31,,,percent of total billed charges,,,348.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,348.41,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,244.65,,,percent of total billed charges,,
LEVOTHYROXINE 100 MCG INJ,2500012794,CDM,636,RC,J0650,HCPCS,4202320101,NDC,436,EAPG,,outpatient,facility,100,UN,348.41,348.41,126.95,186.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.11,,,fee schedule,,,126.95,,,fee schedule,,,165.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 2  2 ML AMP,2500012815,CDM,636,RC,J2003,HCPCS,6332349527,NDC,,,,inpatient,facility,2,UN,9.67,9.67,0.77,9.67,,,,,,,,,,,,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.7,,,percent of total billed charges,,,,,,,,,9.67,,,percent of total billed charges,,,5.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,9.67,,,percent of total billed charges,,,5.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.79,,,percent of total billed charges,,
LIDOCAINE 2  2 ML AMP,2500012815,CDM,636,RC,J2003,HCPCS,6332349527,NDC,,,,outpatient,facility,2,UN,9.67,9.67,0.77,618.77,,5.65,,,percent of total billed charges,,,1.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.67,,,percent of total billed charges,,,8.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,8.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,8.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.7,,,percent of total billed charges,,,,,,,,,9.67,,,percent of total billed charges,,,6.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.04,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.35,,,percent of total billed charges,,,3.66,,,percent of total billed charges,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.58,,,percent of total billed charges,,,3.58,,,percent of total billed charges,,,9.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.77,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,9.67,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,,,,,,,9.67,,,fee schedule,,,9,,,percent of total billed charges,,,,,,,,,,,,,,,9,,,percent of total billed charges,,,9,,,percent of total billed charges,,,9,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,9.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.67,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.79,,,percent of total billed charges,,
LIDOCAINE 2  2 ML AMP,2500012815,CDM,636,RC,J2003,HCPCS,6332349527,NDC,999,EAPG,,outpatient,facility,2,UN,9.67,9.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 2 5 ML LOCAL INJ,2500012818,CDM,250,RC,J2003,HCPCS,409913705,NDC,,,,inpatient,facility,5,UN,30.72,30.72,2.46,30.72,,,,,,,,,,,,,,30.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.65,,,percent of total billed charges,,,,,,,,,30.72,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.72,,,percent of total billed charges,,,,,,,,,,,,,,,30.72,,,percent of total billed charges,,,16.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,30.72,,,percent of total billed charges,,,30.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.57,,,percent of total billed charges,,
LIDOCAINE 2 5 ML LOCAL INJ,2500012818,CDM,250,RC,J2003,HCPCS,409913705,NDC,,,,outpatient,facility,5,UN,30.72,30.72,2.46,618.77,,17.94,,,percent of total billed charges,,,5.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,30.72,,,percent of total billed charges,,,27.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,27.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,27.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,27.65,,,percent of total billed charges,,,,,,,,,30.72,,,percent of total billed charges,,,20.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,30.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.02,,,percent of total billed charges,,,30.72,,,percent of total billed charges,,,30.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.35,,,percent of total billed charges,,,11.64,,,percent of total billed charges,,,15.91,,,percent of total billed charges,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,11.37,,,percent of total billed charges,,,11.37,,,percent of total billed charges,,,30.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.46,,,percent of total billed charges,,,30.72,,,percent of total billed charges,,,30.72,,,percent of total billed charges,,,,,,,,,,,,,,,30.72,,,percent of total billed charges,,,30.72,,,percent of total billed charges,,,,,,,,,30.72,,,fee schedule,,,28.58,,,percent of total billed charges,,,,,,,,,,,,,,,28.58,,,percent of total billed charges,,,28.58,,,percent of total billed charges,,,28.58,,,percent of total billed charges,,,23.04,,,percent of total billed charges,,,30.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,30.72,,,percent of total billed charges,,,30.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,21.57,,,percent of total billed charges,,
LIDOCAINE 2 5 ML LOCAL INJ,2500012818,CDM,250,RC,J2003,HCPCS,409913705,NDC,999,EAPG,,outpatient,facility,5,UN,30.72,30.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 1 /10 ML INJ MPF,2500012823,CDM,250,RC,J2003,HCPCS,6332349297,NDC,,,,inpatient,facility,10,UN,19.64,19.64,1.57,19.64,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.68,,,percent of total billed charges,,,,,,,,,19.64,,,percent of total billed charges,,,10.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,10.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.79,,,percent of total billed charges,,
LIDOCAINE HCL 1 /10 ML INJ MPF,2500012823,CDM,250,RC,J2003,HCPCS,6332349297,NDC,,,,outpatient,facility,10,UN,19.64,19.64,1.57,618.77,,11.47,,,percent of total billed charges,,,3.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,19.64,,,percent of total billed charges,,,17.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,17.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,17.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,17.68,,,percent of total billed charges,,,,,,,,,19.64,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.24,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.93,,,percent of total billed charges,,,7.44,,,percent of total billed charges,,,10.17,,,percent of total billed charges,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.27,,,percent of total billed charges,,,7.27,,,percent of total billed charges,,,19.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.57,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,19.64,,,fee schedule,,,18.27,,,percent of total billed charges,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,14.73,,,percent of total billed charges,,,19.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,19.64,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,13.79,,,percent of total billed charges,,
LIDOCAINE HCL 1 /10 ML INJ MPF,2500012823,CDM,250,RC,J2003,HCPCS,6332349297,NDC,999,EAPG,,outpatient,facility,10,UN,19.64,19.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 1   2 ML AMP,2500012824,CDM,250,RC,J2003,HCPCS,6332349227,NDC,,,,inpatient,facility,2,UN,7.79,7.79,0.62,7.79,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.01,,,percent of total billed charges,,,,,,,,,7.79,,,percent of total billed charges,,,4.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,
LIDOCAINE HCL 1   2 ML AMP,2500012824,CDM,250,RC,J2003,HCPCS,6332349227,NDC,,,,outpatient,facility,2,UN,7.79,7.79,0.62,618.77,,4.55,,,percent of total billed charges,,,1.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.79,,,percent of total billed charges,,,6.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.01,,,percent of total billed charges,,,,,,,,,7.79,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.92,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.88,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,7.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.62,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,7.79,,,fee schedule,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,5.84,,,percent of total billed charges,,,7.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.79,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.47,,,percent of total billed charges,,
LIDOCAINE HCL 1   2 ML AMP,2500012824,CDM,250,RC,J2003,HCPCS,6332349227,NDC,999,EAPG,,outpatient,facility,2,UN,7.79,7.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 1   20ML INJ MDV,2500012825,CDM,250,RC,J2003,HCPCS,5515025220,NDC,,,,inpatient,facility,20,ML,14.65,14.65,1.17,14.65,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.19,,,percent of total billed charges,,,,,,,,,14.65,,,percent of total billed charges,,,8.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.29,,,percent of total billed charges,,
LIDOCAINE HCL 1   20ML INJ MDV,2500012825,CDM,250,RC,J2003,HCPCS,5515025220,NDC,,,,outpatient,facility,20,ML,14.65,14.65,1.17,618.77,,8.56,,,percent of total billed charges,,,2.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.65,,,percent of total billed charges,,,12.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.19,,,percent of total billed charges,,,,,,,,,14.65,,,percent of total billed charges,,,9.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.13,,,percent of total billed charges,,,5.55,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.42,,,percent of total billed charges,,,5.42,,,percent of total billed charges,,,14.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.17,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,14.65,,,fee schedule,,,13.63,,,percent of total billed charges,,,,,,,,,,,,,,,13.63,,,percent of total billed charges,,,13.63,,,percent of total billed charges,,,13.63,,,percent of total billed charges,,,10.99,,,percent of total billed charges,,,14.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.65,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.33,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.29,,,percent of total billed charges,,
LIDOCAINE HCL 1   20ML INJ MDV,2500012825,CDM,250,RC,J2003,HCPCS,5515025220,NDC,999,EAPG,,outpatient,facility,20,ML,14.65,14.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 100 MG/5 ML SYR,2500012832,CDM,636,RC,J2003,HCPCS,409490334,NDC,,,,inpatient,facility,5,ML,20.69,20.69,1.66,20.69,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.62,,,percent of total billed charges,,,,,,,,,20.69,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,10.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.53,,,percent of total billed charges,,
LIDOCAINE HCL 100 MG/5 ML SYR,2500012832,CDM,636,RC,J2003,HCPCS,409490334,NDC,,,,outpatient,facility,5,ML,20.69,20.69,1.66,618.77,,12.08,,,percent of total billed charges,,,4.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,20.69,,,percent of total billed charges,,,18.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,18.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,18.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,18.62,,,percent of total billed charges,,,,,,,,,20.69,,,percent of total billed charges,,,14.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.89,,,percent of total billed charges,,,,,,,,,,,,,,,11.17,,,percent of total billed charges,,,11.17,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.79,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.72,,,percent of total billed charges,,,7.84,,,percent of total billed charges,,,10.72,,,percent of total billed charges,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.66,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,20.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.66,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,,,,,,,20.69,,,fee schedule,,,19.25,,,percent of total billed charges,,,,,,,,,,,,,,,19.25,,,percent of total billed charges,,,19.25,,,percent of total billed charges,,,19.25,,,percent of total billed charges,,,15.52,,,percent of total billed charges,,,20.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,14.53,,,percent of total billed charges,,
LIDOCAINE HCL 100 MG/5 ML SYR,2500012832,CDM,636,RC,J2003,HCPCS,409490334,NDC,999,EAPG,,outpatient,facility,5,ML,20.69,20.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 2  JELLY 5 ML,2500012839,CDM,637,RC,1747871131,NDC,,,,,,inpatient,facility,5,UN,27.72,27.72,2.22,27.72,,,,,,,,,,,,,,27.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.95,,,percent of total billed charges,,,,,,,,,27.72,,,percent of total billed charges,,,15.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.72,,,percent of total billed charges,,,,,,,,,,,,,,,27.72,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,,27.72,,,percent of total billed charges,,,27.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.46,,,percent of total billed charges,,
LIDOCAINE HCL 2  JELLY 5 ML,2500012839,CDM,637,RC,1747871131,NDC,,,,,,outpatient,facility,5,UN,27.72,27.72,2.22,618.77,,16.19,,,percent of total billed charges,,,5.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,27.72,,,percent of total billed charges,,,24.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,24.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,24.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,27.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,24.95,,,percent of total billed charges,,,,,,,,,27.72,,,percent of total billed charges,,,18.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.29,,,percent of total billed charges,,,,,,,,,,,,,,,14.97,,,percent of total billed charges,,,14.97,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,27.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.45,,,percent of total billed charges,,,27.72,,,percent of total billed charges,,,27.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.07,,,percent of total billed charges,,,10.5,,,percent of total billed charges,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.26,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,27.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.22,,,percent of total billed charges,,,27.72,,,percent of total billed charges,,,27.72,,,percent of total billed charges,,,,,,,,,,,,,,,27.72,,,percent of total billed charges,,,27.72,,,percent of total billed charges,,,,,,,,,27.72,,,fee schedule,,,25.79,,,percent of total billed charges,,,,,,,,,,,,,,,25.79,,,percent of total billed charges,,,25.79,,,percent of total billed charges,,,25.79,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,27.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,27.72,,,percent of total billed charges,,,27.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.86,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,19.46,,,percent of total billed charges,,
LIDOCAINE HCL 2  JELLY 5 ML,2500012839,CDM,637,RC,1747871131,NDC,999,EAPG,,,,outpatient,facility,5,UN,27.72,27.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 2  URO-JET 20 ML,2500012840,CDM,637,RC,7632930155,NDC,,,,,,inpatient,facility,20,UN,33.56,33.56,2.68,33.56,,,,,,,,,,,,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.2,,,percent of total billed charges,,,,,,,,,33.56,,,percent of total billed charges,,,18.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,33.56,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.57,,,percent of total billed charges,,
LIDOCAINE HCL 2  URO-JET 20 ML,2500012840,CDM,637,RC,7632930155,NDC,,,,,,outpatient,facility,20,UN,33.56,33.56,2.68,618.77,,19.6,,,percent of total billed charges,,,6.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,33.56,,,percent of total billed charges,,,29.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,29.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,29.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,12.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,30.2,,,percent of total billed charges,,,,,,,,,33.56,,,percent of total billed charges,,,22.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.77,,,percent of total billed charges,,,,,,,,,,,,,,,18.12,,,percent of total billed charges,,,18.12,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.5,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,,percent of total billed charges,,,12.71,,,percent of total billed charges,,,17.38,,,percent of total billed charges,,,,,,,,,,,,,,,6.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,12.42,,,percent of total billed charges,,,12.42,,,percent of total billed charges,,,33.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.68,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,33.56,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,,,,,,,33.56,,,fee schedule,,,31.22,,,percent of total billed charges,,,,,,,,,,,,,,,31.22,,,percent of total billed charges,,,31.22,,,percent of total billed charges,,,31.22,,,percent of total billed charges,,,25.17,,,percent of total billed charges,,,33.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,33.56,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,23.57,,,percent of total billed charges,,
LIDOCAINE HCL 2  URO-JET 20 ML,2500012840,CDM,637,RC,7632930155,NDC,999,EAPG,,,,outpatient,facility,20,UN,33.56,33.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 4  TOP 50 ML INJ,2500012849,CDM,637,RC,5256500950,NDC,,,,,,inpatient,facility,50,UN,158.4,158.4,12.67,158.4,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.56,,,percent of total billed charges,,,,,,,,,158.4,,,percent of total billed charges,,,87.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,82.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.67,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.23,,,percent of total billed charges,,
LIDOCAINE HCL 4  TOP 50 ML INJ,2500012849,CDM,637,RC,5256500950,NDC,,,,,,outpatient,facility,50,UN,158.4,158.4,12.67,618.77,,92.51,,,percent of total billed charges,,,30.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,158.4,,,percent of total billed charges,,,139.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,139.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,139.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,57.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,142.56,,,percent of total billed charges,,,,,,,,,158.4,,,percent of total billed charges,,,107.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.65,,,percent of total billed charges,,,,,,,,,,,,,,,85.54,,,percent of total billed charges,,,85.54,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.59,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.38,,,percent of total billed charges,,,60,,,percent of total billed charges,,,82.04,,,percent of total billed charges,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,58.61,,,percent of total billed charges,,,58.61,,,percent of total billed charges,,,158.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,158.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.67,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,,,,,,,158.4,,,fee schedule,,,147.34,,,percent of total billed charges,,,,,,,,,,,,,,,147.34,,,percent of total billed charges,,,147.34,,,percent of total billed charges,,,147.34,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,158.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,158.4,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,111.23,,,percent of total billed charges,,
LIDOCAINE HCL 4  TOP 50 ML INJ,2500012849,CDM,637,RC,5256500950,NDC,999,EAPG,,,,outpatient,facility,50,UN,158.4,158.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 5  OINT 35 GM,2500012850,CDM,637,RC,6846241820,NDC,,,,,,inpatient,facility,35,UN,34.65,34.65,2.77,34.65,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.18,,,percent of total billed charges,,,,,,,,,34.65,,,percent of total billed charges,,,19.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,18.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.33,,,percent of total billed charges,,
LIDOCAINE HCL 5  OINT 35 GM,2500012850,CDM,637,RC,6846241820,NDC,,,,,,outpatient,facility,35,UN,34.65,34.65,2.77,618.77,,20.24,,,percent of total billed charges,,,6.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,34.65,,,percent of total billed charges,,,30.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,30.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,30.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,12.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,31.18,,,percent of total billed charges,,,,,,,,,34.65,,,percent of total billed charges,,,23.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.61,,,percent of total billed charges,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.07,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.33,,,percent of total billed charges,,,13.13,,,percent of total billed charges,,,17.95,,,percent of total billed charges,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,12.82,,,percent of total billed charges,,,12.82,,,percent of total billed charges,,,34.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,34.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,34.65,,,fee schedule,,,32.23,,,percent of total billed charges,,,,,,,,,,,,,,,32.23,,,percent of total billed charges,,,32.23,,,percent of total billed charges,,,32.23,,,percent of total billed charges,,,25.99,,,percent of total billed charges,,,34.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,24.33,,,percent of total billed charges,,
LIDOCAINE HCL 5  OINT 35 GM,2500012850,CDM,637,RC,6846241820,NDC,999,EAPG,,,,outpatient,facility,35,UN,34.65,34.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 5  PATCH,2500012852,CDM,637,RC,591352530,NDC,,,,,,inpatient,facility,1,UN,30.89,30.89,2.47,30.89,,,,,,,,,,,,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.8,,,percent of total billed charges,,,,,,,,,30.89,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,30.89,,,percent of total billed charges,,,16.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.69,,,percent of total billed charges,,
LIDOCAINE HCL 5  PATCH,2500012852,CDM,637,RC,591352530,NDC,,,,,,outpatient,facility,1,UN,30.89,30.89,2.47,618.77,,18.04,,,percent of total billed charges,,,6.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,30.89,,,percent of total billed charges,,,27.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,27.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,27.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,27.8,,,percent of total billed charges,,,,,,,,,30.89,,,percent of total billed charges,,,20.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.72,,,percent of total billed charges,,,,,,,,,,,,,,,16.68,,,percent of total billed charges,,,16.68,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.11,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.48,,,percent of total billed charges,,,11.7,,,percent of total billed charges,,,16,,,percent of total billed charges,,,,,,,,,,,,,,,6.18,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,11.43,,,percent of total billed charges,,,11.43,,,percent of total billed charges,,,30.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.47,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,30.89,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,,,,,,,30.89,,,fee schedule,,,28.73,,,percent of total billed charges,,,,,,,,,,,,,,,28.73,,,percent of total billed charges,,,28.73,,,percent of total billed charges,,,28.73,,,percent of total billed charges,,,23.17,,,percent of total billed charges,,,30.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,30.89,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,21.69,,,percent of total billed charges,,
LIDOCAINE HCL 5  PATCH,2500012852,CDM,637,RC,591352530,NDC,999,EAPG,,,,outpatient,facility,1,UN,30.89,30.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 2  VISC 15ML UDC,2500012855,CDM,637,RC,5038336317,NDC,,,,,,inpatient,facility,15,UN,3.56,3.56,0.28,3.56,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,
LIDOCAINE HCL 2  VISC 15ML UDC,2500012855,CDM,637,RC,5038336317,NDC,,,,,,outpatient,facility,15,UN,3.56,3.56,0.28,618.77,,2.08,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.56,,,percent of total billed charges,,,3.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.2,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,3.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,3.56,,,fee schedule,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,3.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.5,,,percent of total billed charges,,
LIDOCAINE HCL 2  VISC 15ML UDC,2500012855,CDM,637,RC,5038336317,NDC,999,EAPG,,,,outpatient,facility,15,UN,3.56,3.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE/PRILOCAINE 5 GM KIT,2500012868,CDM,637,RC,168035756,NDC,,,,,,inpatient,facility,5,UN,136.36,136.36,10.91,136.36,,,,,,,,,,,,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.72,,,percent of total billed charges,,,,,,,,,136.36,,,percent of total billed charges,,,75.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,136.36,,,percent of total billed charges,,,71.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.91,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.75,,,percent of total billed charges,,
LIDOCAINE/PRILOCAINE 5 GM KIT,2500012868,CDM,637,RC,168035756,NDC,,,,,,outpatient,facility,5,UN,136.36,136.36,10.91,618.77,,79.63,,,percent of total billed charges,,,26.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,136.36,,,percent of total billed charges,,,120.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,120.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,120.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,49.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,122.72,,,percent of total billed charges,,,,,,,,,136.36,,,percent of total billed charges,,,92.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.72,,,percent of total billed charges,,,,,,,,,,,,,,,73.63,,,percent of total billed charges,,,73.63,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.1,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.63,,,percent of total billed charges,,,51.65,,,percent of total billed charges,,,70.62,,,percent of total billed charges,,,,,,,,,,,,,,,27.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,50.45,,,percent of total billed charges,,,50.45,,,percent of total billed charges,,,136.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,136.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.91,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,136.36,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,,,,,,,136.36,,,fee schedule,,,126.84,,,percent of total billed charges,,,,,,,,,,,,,,,126.84,,,percent of total billed charges,,,126.84,,,percent of total billed charges,,,126.84,,,percent of total billed charges,,,102.27,,,percent of total billed charges,,,136.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,136.36,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,95.75,,,percent of total billed charges,,
LIDOCAINE/PRILOCAINE 5 GM KIT,2500012868,CDM,637,RC,168035756,NDC,999,EAPG,,,,outpatient,facility,5,UN,136.36,136.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEZOLID 600 MG TAB,2500012880,CDM,637,RC,904655304,NDC,,,,,,inpatient,facility,600,UN,20.43,20.43,1.63,20.43,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.39,,,percent of total billed charges,,,,,,,,,20.43,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,10.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.35,,,percent of total billed charges,,
LINEZOLID 600 MG TAB,2500012880,CDM,637,RC,904655304,NDC,,,,,,outpatient,facility,600,UN,20.43,20.43,1.63,618.77,,11.93,,,percent of total billed charges,,,3.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,20.43,,,percent of total billed charges,,,17.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,17.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,17.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,18.39,,,percent of total billed charges,,,,,,,,,20.43,,,percent of total billed charges,,,13.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.69,,,percent of total billed charges,,,,,,,,,,,,,,,11.03,,,percent of total billed charges,,,11.03,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.65,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.53,,,percent of total billed charges,,,7.74,,,percent of total billed charges,,,10.58,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.56,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,20.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.63,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,,,,,,,20.43,,,fee schedule,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,19,,,percent of total billed charges,,,19,,,percent of total billed charges,,,19,,,percent of total billed charges,,,15.32,,,percent of total billed charges,,,20.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,20.43,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,14.35,,,percent of total billed charges,,
LINEZOLID 600 MG TAB,2500012880,CDM,637,RC,904655304,NDC,999,EAPG,,,,outpatient,facility,600,UN,20.43,20.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEZOLID 600MG PREMIX IN 300,2500012885,CDM,636,RC,J2020,HCPCS,5766468357,NDC,,,,inpatient,facility,300,UN,82.5,82.5,6.6,82.5,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.25,,,percent of total billed charges,,,,,,,,,82.5,,,percent of total billed charges,,,45.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,43.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.93,,,percent of total billed charges,,
LINEZOLID 600MG PREMIX IN 300,2500012885,CDM,636,RC,J2020,HCPCS,5766468357,NDC,,,,outpatient,facility,300,UN,82.5,82.5,2.72,618.77,,48.18,,,percent of total billed charges,,,16.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,82.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,30.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,74.25,,,percent of total billed charges,,,,,,,,,82.5,,,percent of total billed charges,,,55.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.36,,,percent of total billed charges,,,,,,,,,,,,,,,3.3,,,fee schedule,,,3.3,,,fee schedule,,,,,,,,,618.77,,,per diem,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.02,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.7,,,percent of total billed charges,,,31.25,,,percent of total billed charges,,,42.73,,,percent of total billed charges,,,,,,,,,,,,,,,16.5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,82.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,82.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.6,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,82.5,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.72,,,fee schedule,,,82.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,57.93,,,percent of total billed charges,,
LINEZOLID 600MG PREMIX IN 300,2500012885,CDM,636,RC,J2020,HCPCS,5766468357,NDC,435,EAPG,,outpatient,facility,300,UN,82.5,82.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIOTHYRONINE  SOD 25 MCG TAB,2500012890,CDM,637,RC,5186232101,NDC,,,,,,inpatient,facility,25,UN,8.18,8.18,0.65,8.18,,,,,,,,,,,,,,8.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,,,,,,,8.18,,,percent of total billed charges,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.18,,,percent of total billed charges,,,,,,,,,,,,,,,8.18,,,percent of total billed charges,,,4.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,8.18,,,percent of total billed charges,,,8.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,
LIOTHYRONINE  SOD 25 MCG TAB,2500012890,CDM,637,RC,5186232101,NDC,,,,,,outpatient,facility,25,UN,8.18,8.18,0.65,618.77,,4.78,,,percent of total billed charges,,,1.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.18,,,percent of total billed charges,,,7.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.36,,,percent of total billed charges,,,,,,,,,8.18,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.28,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.27,,,percent of total billed charges,,,8.18,,,percent of total billed charges,,,8.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.22,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,4.24,,,percent of total billed charges,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.03,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,8.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.65,,,percent of total billed charges,,,8.18,,,percent of total billed charges,,,8.18,,,percent of total billed charges,,,,,,,,,,,,,,,8.18,,,percent of total billed charges,,,8.18,,,percent of total billed charges,,,,,,,,,8.18,,,fee schedule,,,7.61,,,percent of total billed charges,,,,,,,,,,,,,,,7.61,,,percent of total billed charges,,,7.61,,,percent of total billed charges,,,7.61,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,8.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.18,,,percent of total billed charges,,,8.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.74,,,percent of total billed charges,,
LIOTHYRONINE  SOD 25 MCG TAB,2500012890,CDM,637,RC,5186232101,NDC,999,EAPG,,,,outpatient,facility,25,UN,8.18,8.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIPASE/AMYLASE/PROTEASE CAP,2500012914,CDM,637,RC,32263601,NDC,,,,,,inpatient,facility,24000,UN,27.16,27.16,2.17,27.16,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.44,,,percent of total billed charges,,,,,,,,,27.16,,,percent of total billed charges,,,15.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,14.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.07,,,percent of total billed charges,,
LIPASE/AMYLASE/PROTEASE CAP,2500012914,CDM,637,RC,32263601,NDC,,,,,,outpatient,facility,24000,UN,27.16,27.16,2.17,618.77,,15.86,,,percent of total billed charges,,,5.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,27.16,,,percent of total billed charges,,,23.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,23.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,23.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,24.44,,,percent of total billed charges,,,,,,,,,27.16,,,percent of total billed charges,,,18.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.86,,,percent of total billed charges,,,,,,,,,,,,,,,14.67,,,percent of total billed charges,,,14.67,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.16,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.64,,,percent of total billed charges,,,10.29,,,percent of total billed charges,,,14.07,,,percent of total billed charges,,,,,,,,,,,,,,,5.43,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.05,,,percent of total billed charges,,,10.05,,,percent of total billed charges,,,27.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.17,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,,,,,,,27.16,,,fee schedule,,,25.26,,,percent of total billed charges,,,,,,,,,,,,,,,25.26,,,percent of total billed charges,,,25.26,,,percent of total billed charges,,,25.26,,,percent of total billed charges,,,20.37,,,percent of total billed charges,,,27.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,27.16,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,19.07,,,percent of total billed charges,,
LIPASE/AMYLASE/PROTEASE CAP,2500012914,CDM,637,RC,32263601,NDC,999,EAPG,,,,outpatient,facility,24000,UN,27.16,27.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LISINOPRIL 10 MG TAB,2500012930,CDM,637,RC,6818098003,NDC,,,,,,inpatient,facility,10,UN,3.23,3.23,0.26,3.23,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.27,,,percent of total billed charges,,
LISINOPRIL 10 MG TAB,2500012930,CDM,637,RC,6818098003,NDC,,,,,,outpatient,facility,10,UN,3.23,3.23,0.26,618.77,,1.89,,,percent of total billed charges,,,0.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.23,,,percent of total billed charges,,,2.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.91,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,3.23,,,fee schedule,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,3.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.27,,,percent of total billed charges,,
LISINOPRIL 10 MG TAB,2500012930,CDM,637,RC,6818098003,NDC,999,EAPG,,,,outpatient,facility,10,UN,3.23,3.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LISINOPRIL 20 MG TAB,2500012932,CDM,637,RC,904679961,NDC,,,,,,inpatient,facility,20,UN,0.23,0.23,0.02,0.23,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,
LISINOPRIL 20 MG TAB,2500012932,CDM,637,RC,904679961,NDC,,,,,,outpatient,facility,20,UN,0.23,0.23,0.02,618.77,,0.13,,,percent of total billed charges,,,0.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.21,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,0.09,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.09,,,percent of total billed charges,,,0.09,,,percent of total billed charges,,,0.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,0.23,,,fee schedule,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.16,,,percent of total billed charges,,
LISINOPRIL 20 MG TAB,2500012932,CDM,637,RC,904679961,NDC,999,EAPG,,,,outpatient,facility,20,UN,0.23,0.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LISINOPRIL 5 MG TAB,2500012934,CDM,637,RC,904679761,NDC,,,,,,inpatient,facility,5,UN,0.19,0.19,0.02,0.19,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,0.19,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,
LISINOPRIL 5 MG TAB,2500012934,CDM,637,RC,904679761,NDC,,,,,,outpatient,facility,5,UN,0.19,0.19,0.02,618.77,,0.11,,,percent of total billed charges,,,0.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,0.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.17,,,percent of total billed charges,,,,,,,,,0.19,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.07,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,,,,,,,0.19,,,fee schedule,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,0.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.19,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.13,,,percent of total billed charges,,
LISINOPRIL 5 MG TAB,2500012934,CDM,637,RC,904679761,NDC,999,EAPG,,,,outpatient,facility,5,UN,0.19,0.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LITHIUM CARBONATE 150 MG CAP,2500012940,CDM,637,RC,54852625,NDC,,,,,,inpatient,facility,150,UN,0.62,0.62,0.05,0.62,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,
LITHIUM CARBONATE 150 MG CAP,2500012940,CDM,637,RC,54852625,NDC,,,,,,outpatient,facility,150,UN,0.62,0.62,0.05,618.77,,0.36,,,percent of total billed charges,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.62,,,percent of total billed charges,,,0.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.56,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,0.62,,,fee schedule,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.44,,,percent of total billed charges,,
LITHIUM CARBONATE 150 MG CAP,2500012940,CDM,637,RC,54852625,NDC,999,EAPG,,,,outpatient,facility,150,UN,0.62,0.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LITHIUM CARBONATE 300 MG TAB,2500012943,CDM,637,RC,54852825,NDC,,,,,,inpatient,facility,300,UN,1.12,1.12,0.09,1.12,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,1.12,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,
LITHIUM CARBONATE 300 MG TAB,2500012943,CDM,637,RC,54852825,NDC,,,,,,outpatient,facility,300,UN,1.12,1.12,0.09,618.77,,0.65,,,percent of total billed charges,,,0.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.12,,,percent of total billed charges,,,0.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.01,,,percent of total billed charges,,,,,,,,,1.12,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.41,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,1.12,,,fee schedule,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,1.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.79,,,percent of total billed charges,,
LITHIUM CARBONATE 300 MG TAB,2500012943,CDM,637,RC,54852825,NDC,999,EAPG,,,,outpatient,facility,300,UN,1.12,1.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LITHIUM CARBONATE 450 MG TABCR,2500012945,CDM,637,RC,5107914220,NDC,,,,,,inpatient,facility,450,UN,2.51,2.51,0.2,2.51,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,2.51,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,
LITHIUM CARBONATE 450 MG TABCR,2500012945,CDM,637,RC,5107914220,NDC,,,,,,outpatient,facility,450,UN,2.51,2.51,0.2,618.77,,1.47,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.51,,,percent of total billed charges,,,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.26,,,percent of total billed charges,,,,,,,,,2.51,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.93,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,2.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,2.51,,,fee schedule,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,2.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.76,,,percent of total billed charges,,
LITHIUM CARBONATE 450 MG TABCR,2500012945,CDM,637,RC,5107914220,NDC,999,EAPG,,,,outpatient,facility,450,UN,2.51,2.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LITHIUM CARBONATE SR 300MG TAB,2500012960,CDM,637,RC,6808464001,NDC,,,,,,inpatient,facility,300,UN,1.58,1.58,0.13,1.58,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,1.58,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,
LITHIUM CARBONATE SR 300MG TAB,2500012960,CDM,637,RC,6808464001,NDC,,,,,,outpatient,facility,300,UN,1.58,1.58,0.13,618.77,,0.92,,,percent of total billed charges,,,0.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.58,,,percent of total billed charges,,,1.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.42,,,percent of total billed charges,,,,,,,,,1.58,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,1.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,1.58,,,fee schedule,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.11,,,percent of total billed charges,,
LITHIUM CARBONATE SR 300MG TAB,2500012960,CDM,637,RC,6808464001,NDC,999,EAPG,,,,outpatient,facility,300,UN,1.58,1.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LOPERAMIDE  2 MG CAP,2500012982,CDM,637,RC,6068722901,NDC,,,,,,inpatient,facility,2,UN,3.36,3.36,0.27,3.36,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.02,,,percent of total billed charges,,,,,,,,,3.36,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,
LOPERAMIDE  2 MG CAP,2500012982,CDM,637,RC,6068722901,NDC,,,,,,outpatient,facility,2,UN,3.36,3.36,0.27,618.77,,1.96,,,percent of total billed charges,,,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.36,,,percent of total billed charges,,,2.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.02,,,percent of total billed charges,,,,,,,,,3.36,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.24,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,3.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.27,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,3.36,,,fee schedule,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,3.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.36,,,percent of total billed charges,,
LOPERAMIDE  2 MG CAP,2500012982,CDM,637,RC,6068722901,NDC,999,EAPG,,,,outpatient,facility,2,UN,3.36,3.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIOTHYRONINE SODIUM 5 MCG TAB,2500012984,CDM,637,RC,5186232001,NDC,,,,,,inpatient,facility,5,UN,6.23,6.23,0.5,6.23,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,6.23,,,percent of total billed charges,,,3.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,3.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,
LIOTHYRONINE SODIUM 5 MCG TAB,2500012984,CDM,637,RC,5186232001,NDC,,,,,,outpatient,facility,5,UN,6.23,6.23,0.5,618.77,,3.64,,,percent of total billed charges,,,1.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.23,,,percent of total billed charges,,,5.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.61,,,percent of total billed charges,,,,,,,,,6.23,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.25,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.73,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,6.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.5,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,6.23,,,fee schedule,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,6.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.37,,,percent of total billed charges,,
LIOTHYRONINE SODIUM 5 MCG TAB,2500012984,CDM,637,RC,5186232001,NDC,999,EAPG,,,,outpatient,facility,5,UN,6.23,6.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LORATADINE 10 MG TAB,2500013010,CDM,637,RC,5002442903,NDC,,,,,,inpatient,facility,10,UN,1.21,1.21,0.1,1.21,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,1.21,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,
LORATADINE 10 MG TAB,2500013010,CDM,637,RC,5002442903,NDC,,,,,,outpatient,facility,10,UN,1.21,1.21,0.1,618.77,,0.71,,,percent of total billed charges,,,0.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.21,,,percent of total billed charges,,,1.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.09,,,percent of total billed charges,,,,,,,,,1.21,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.45,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,1.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,1.21,,,fee schedule,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,1.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.21,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.85,,,percent of total billed charges,,
LORATADINE 10 MG TAB,2500013010,CDM,637,RC,5002442903,NDC,999,EAPG,,,,outpatient,facility,10,UN,1.21,1.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LORATADINE 5 MG LIQUID,2500013011,CDM,637,RC,5167221318,NDC,,,,,,inpatient,facility,5,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
LORATADINE 5 MG LIQUID,2500013011,CDM,637,RC,5167221318,NDC,,,,,,outpatient,facility,5,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
LORATADINE 5 MG LIQUID,2500013011,CDM,637,RC,5167221318,NDC,999,EAPG,,,,outpatient,facility,5,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LORAZEPAM 0.5 MG TAB,2500013030,CDM,637,RC,6931590401,NDC,,,,,,inpatient,facility,0.5,UN,2.11,2.11,0.17,2.11,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,2.11,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,
LORAZEPAM 0.5 MG TAB,2500013030,CDM,637,RC,6931590401,NDC,,,,,,outpatient,facility,0.5,UN,2.11,2.11,0.17,618.77,,1.23,,,percent of total billed charges,,,0.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.11,,,percent of total billed charges,,,1.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.9,,,percent of total billed charges,,,,,,,,,2.11,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.78,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,2.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,2.11,,,fee schedule,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,2.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.48,,,percent of total billed charges,,
LORAZEPAM 0.5 MG TAB,2500013030,CDM,637,RC,6931590401,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,2.11,2.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LORAZEPAM 1 MG TAB,2500013031,CDM,637,RC,6931590501,NDC,,,,,,inpatient,facility,1,UN,2.77,2.77,0.22,2.77,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,
LORAZEPAM 1 MG TAB,2500013031,CDM,637,RC,6931590501,NDC,,,,,,outpatient,facility,1,UN,2.77,2.77,0.22,618.77,,1.62,,,percent of total billed charges,,,0.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,2.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.49,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,2.77,,,fee schedule,,,2.58,,,percent of total billed charges,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.95,,,percent of total billed charges,,
LORAZEPAM 1 MG TAB,2500013031,CDM,637,RC,6931590501,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.77,2.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LORAZEPAM 2 MG/ML 1ML ORAL SYR,2500013033,CDM,637,RC,54353244,NDC,,,,,,inpatient,facility,1,UN,5.28,5.28,0.42,5.28,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,5.28,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.71,,,percent of total billed charges,,
LORAZEPAM 2 MG/ML 1ML ORAL SYR,2500013033,CDM,637,RC,54353244,NDC,,,,,,outpatient,facility,1,UN,5.28,5.28,0.42,618.77,,3.08,,,percent of total billed charges,,,1.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.28,,,percent of total billed charges,,,4.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.75,,,percent of total billed charges,,,,,,,,,5.28,,,percent of total billed charges,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,5.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.42,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,5.28,,,fee schedule,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,5.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.71,,,percent of total billed charges,,
LORAZEPAM 2 MG/ML 1ML ORAL SYR,2500013033,CDM,637,RC,54353244,NDC,999,EAPG,,,,outpatient,facility,1,UN,5.28,5.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LOSARTAN POTASSIUM 25 MG TAB,2500013050,CDM,637,RC,904704761,NDC,,,,,,inpatient,facility,25,UN,1.91,1.91,0.15,1.91,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,1.91,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,
LOSARTAN POTASSIUM 25 MG TAB,2500013050,CDM,637,RC,904704761,NDC,,,,,,outpatient,facility,25,UN,1.91,1.91,0.15,618.77,,1.12,,,percent of total billed charges,,,0.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.91,,,percent of total billed charges,,,1.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.72,,,percent of total billed charges,,,,,,,,,1.91,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.71,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,1.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,,,,,,,1.91,,,fee schedule,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,1.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.34,,,percent of total billed charges,,
LOSARTAN POTASSIUM 25 MG TAB,2500013050,CDM,637,RC,904704761,NDC,999,EAPG,,,,outpatient,facility,25,UN,1.91,1.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LOSARTAN POTASSIUM 50 MG TAB,2500013052,CDM,637,RC,904704861,NDC,,,,,,inpatient,facility,50,UN,2.24,2.24,0.18,2.24,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,
LOSARTAN POTASSIUM 50 MG TAB,2500013052,CDM,637,RC,904704861,NDC,,,,,,outpatient,facility,50,UN,2.24,2.24,0.18,618.77,,1.31,,,percent of total billed charges,,,0.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.24,,,percent of total billed charges,,,1.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.02,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,2.24,,,fee schedule,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,2.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.57,,,percent of total billed charges,,
LOSARTAN POTASSIUM 50 MG TAB,2500013052,CDM,637,RC,904704861,NDC,999,EAPG,,,,outpatient,facility,50,UN,2.24,2.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LOXAPINE SUCC 25 MG CAP,2500013072,CDM,637,RC,591037101,NDC,,,,,,inpatient,facility,25,UN,6.33,6.33,0.51,6.33,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,,,,,,,6.33,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.44,,,percent of total billed charges,,
LOXAPINE SUCC 25 MG CAP,2500013072,CDM,637,RC,591037101,NDC,,,,,,outpatient,facility,25,UN,6.33,6.33,0.51,618.77,,3.7,,,percent of total billed charges,,,1.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.33,,,percent of total billed charges,,,5.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.7,,,percent of total billed charges,,,,,,,,,6.33,,,percent of total billed charges,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.86,,,percent of total billed charges,,,,,,,,,,,,,,,3.42,,,percent of total billed charges,,,3.42,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.81,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,6.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.51,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,,,,,,,6.33,,,fee schedule,,,5.89,,,percent of total billed charges,,,,,,,,,,,,,,,5.89,,,percent of total billed charges,,,5.89,,,percent of total billed charges,,,5.89,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,6.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.33,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.44,,,percent of total billed charges,,
LOXAPINE SUCC 25 MG CAP,2500013072,CDM,637,RC,591037101,NDC,999,EAPG,,,,outpatient,facility,25,UN,6.33,6.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAALOX PLUS  30 ML,2500013125,CDM,637,RC,121176130,NDC,,,,,,inpatient,facility,30,UN,5.68,5.68,0.45,5.68,,,,,,,,,,,,,,5.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.11,,,percent of total billed charges,,,,,,,,,5.68,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.68,,,percent of total billed charges,,,,,,,,,,,,,,,5.68,,,percent of total billed charges,,,2.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,5.68,,,percent of total billed charges,,,5.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,
MAALOX PLUS  30 ML,2500013125,CDM,637,RC,121176130,NDC,,,,,,outpatient,facility,30,UN,5.68,5.68,0.45,618.77,,3.32,,,percent of total billed charges,,,1.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.68,,,percent of total billed charges,,,5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.11,,,percent of total billed charges,,,,,,,,,5.68,,,percent of total billed charges,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.36,,,percent of total billed charges,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,,5.68,,,percent of total billed charges,,,5.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.1,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,5.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.45,,,percent of total billed charges,,,5.68,,,percent of total billed charges,,,5.68,,,percent of total billed charges,,,,,,,,,,,,,,,5.68,,,percent of total billed charges,,,5.68,,,percent of total billed charges,,,,,,,,,5.68,,,fee schedule,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,5.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.68,,,percent of total billed charges,,,5.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.99,,,percent of total billed charges,,
MAALOX PLUS  30 ML,2500013125,CDM,637,RC,121176130,NDC,999,EAPG,,,,outpatient,facility,30,UN,5.68,5.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGNESIUM CITRATE 300 ML,2500013190,CDM,637,RC,904678744,NDC,,,,,,inpatient,facility,300,UN,3.16,3.16,0.25,3.16,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,3.16,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,3.16,,,percent of total billed charges,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,
MAGNESIUM CITRATE 300 ML,2500013190,CDM,637,RC,904678744,NDC,,,,,,outpatient,facility,300,UN,3.16,3.16,0.25,618.77,,1.85,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.16,,,percent of total billed charges,,,2.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.84,,,percent of total billed charges,,,,,,,,,3.16,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,3.16,,,percent of total billed charges,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.17,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,3.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.25,,,percent of total billed charges,,,3.16,,,percent of total billed charges,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,3.16,,,percent of total billed charges,,,,,,,,,3.16,,,fee schedule,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,3.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.16,,,percent of total billed charges,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.22,,,percent of total billed charges,,
MAGNESIUM CITRATE 300 ML,2500013190,CDM,637,RC,904678744,NDC,999,EAPG,,,,outpatient,facility,300,UN,3.16,3.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGNESIUM HYDR SUSP 30 ML UDC,2500013210,CDM,637,RC,904684673,NDC,,,,,,inpatient,facility,30,UN,2.55,2.55,0.2,2.55,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.29,,,percent of total billed charges,,,,,,,,,2.55,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.79,,,percent of total billed charges,,
MAGNESIUM HYDR SUSP 30 ML UDC,2500013210,CDM,637,RC,904684673,NDC,,,,,,outpatient,facility,30,UN,2.55,2.55,0.2,618.77,,1.49,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.55,,,percent of total billed charges,,,2.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.29,,,percent of total billed charges,,,,,,,,,2.55,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.94,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,2.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,2.55,,,fee schedule,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,2.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.79,,,percent of total billed charges,,
MAGNESIUM HYDR SUSP 30 ML UDC,2500013210,CDM,637,RC,904684673,NDC,999,EAPG,,,,outpatient,facility,30,UN,2.55,2.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MECLIZINE HCL 12.5 MG TAB,2500013280,CDM,637,RC,5026852215,NDC,,,,,,inpatient,facility,12.5,UN,2.12,2.12,0.17,2.12,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,2.12,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,
MECLIZINE HCL 12.5 MG TAB,2500013280,CDM,637,RC,5026852215,NDC,,,,,,outpatient,facility,12.5,UN,2.12,2.12,0.17,618.77,,1.24,,,percent of total billed charges,,,0.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.12,,,percent of total billed charges,,,1.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.91,,,percent of total billed charges,,,,,,,,,2.12,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.78,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,2.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,2.12,,,fee schedule,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,2.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.49,,,percent of total billed charges,,
MECLIZINE HCL 12.5 MG TAB,2500013280,CDM,637,RC,5026852215,NDC,999,EAPG,,,,outpatient,facility,12.5,UN,2.12,2.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEDROXYPROGESTERONE 2.5 MG TAB,2500013322,CDM,637,RC,555087202,NDC,,,,,,inpatient,facility,2.5,UN,1.02,1.02,0.08,1.02,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,
MEDROXYPROGESTERONE 2.5 MG TAB,2500013322,CDM,637,RC,555087202,NDC,,,,,,outpatient,facility,2.5,UN,1.02,1.02,0.08,618.77,,0.6,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.02,,,percent of total billed charges,,,0.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.92,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.38,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,1.02,,,fee schedule,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,1.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.72,,,percent of total billed charges,,
MEDROXYPROGESTERONE 2.5 MG TAB,2500013322,CDM,637,RC,555087202,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,1.02,1.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEGESTROL ACETATE 20 MG TAB,2500013352,CDM,637,RC,555060602,NDC,,,,,,inpatient,facility,20,UN,3.43,3.43,0.27,3.43,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.09,,,percent of total billed charges,,,,,,,,,3.43,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,
MEGESTROL ACETATE 20 MG TAB,2500013352,CDM,637,RC,555060602,NDC,,,,,,outpatient,facility,20,UN,3.43,3.43,0.27,618.77,,2,,,percent of total billed charges,,,0.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.43,,,percent of total billed charges,,,3.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.09,,,percent of total billed charges,,,,,,,,,3.43,,,percent of total billed charges,,,2.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.79,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.27,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,3.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.27,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,3.43,,,fee schedule,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,,3.19,,,percent of total billed charges,,,3.19,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,3.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.43,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.41,,,percent of total billed charges,,
MEGESTROL ACETATE 20 MG TAB,2500013352,CDM,637,RC,555060602,NDC,999,EAPG,,,,outpatient,facility,20,UN,3.43,3.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEGESTROL SUS 400 MG/10 ML UDC,2500013358,CDM,637,RC,121477640,NDC,,,,,,inpatient,facility,10,UN,14.95,14.95,1.2,14.95,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,,,,,,,14.95,,,percent of total billed charges,,,8.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.5,,,percent of total billed charges,,
MEGESTROL SUS 400 MG/10 ML UDC,2500013358,CDM,637,RC,121477640,NDC,,,,,,outpatient,facility,10,UN,14.95,14.95,1.2,618.77,,8.73,,,percent of total billed charges,,,2.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.95,,,percent of total billed charges,,,13.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,13.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,13.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.46,,,percent of total billed charges,,,,,,,,,14.95,,,percent of total billed charges,,,10.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.48,,,percent of total billed charges,,,,,,,,,,,,,,,8.07,,,percent of total billed charges,,,8.07,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.36,,,percent of total billed charges,,,5.66,,,percent of total billed charges,,,7.74,,,percent of total billed charges,,,,,,,,,,,,,,,2.99,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.53,,,percent of total billed charges,,,5.53,,,percent of total billed charges,,,14.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.2,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,,,,,,,14.95,,,fee schedule,,,13.91,,,percent of total billed charges,,,,,,,,,,,,,,,13.91,,,percent of total billed charges,,,13.91,,,percent of total billed charges,,,13.91,,,percent of total billed charges,,,11.21,,,percent of total billed charges,,,14.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.95,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.5,,,percent of total billed charges,,
MEGESTROL SUS 400 MG/10 ML UDC,2500013358,CDM,637,RC,121477640,NDC,999,EAPG,,,,outpatient,facility,10,UN,14.95,14.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MELATONIN 5 MG TAB,2500013363,CDM,637,RC,7733352010,NDC,,,,,,inpatient,facility,5,UN,1.81,1.81,0.14,1.81,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,,,,,,,1.81,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,
MELATONIN 5 MG TAB,2500013363,CDM,637,RC,7733352010,NDC,,,,,,outpatient,facility,5,UN,1.81,1.81,0.14,618.77,,1.06,,,percent of total billed charges,,,0.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.81,,,percent of total billed charges,,,1.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.63,,,percent of total billed charges,,,,,,,,,1.81,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.67,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,1.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.14,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,1.81,,,fee schedule,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,1.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.27,,,percent of total billed charges,,
MELATONIN 5 MG TAB,2500013363,CDM,637,RC,7733352010,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.81,1.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MELOXICAM 15 MG TAB,2500013365,CDM,637,RC,6909715912,NDC,,,,,,inpatient,facility,15,UN,15.97,15.97,1.28,15.97,,,,,,,,,,,,,,15.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.37,,,percent of total billed charges,,,,,,,,,15.97,,,percent of total billed charges,,,8.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.97,,,percent of total billed charges,,,,,,,,,,,,,,,15.97,,,percent of total billed charges,,,8.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,15.97,,,percent of total billed charges,,,15.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.21,,,percent of total billed charges,,
MELOXICAM 15 MG TAB,2500013365,CDM,637,RC,6909715912,NDC,,,,,,outpatient,facility,15,UN,15.97,15.97,1.28,618.77,,9.33,,,percent of total billed charges,,,3.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,15.97,,,percent of total billed charges,,,14.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,14.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,14.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,14.37,,,percent of total billed charges,,,,,,,,,15.97,,,percent of total billed charges,,,10.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.26,,,percent of total billed charges,,,,,,,,,,,,,,,8.62,,,percent of total billed charges,,,8.62,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,15.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.33,,,percent of total billed charges,,,15.97,,,percent of total billed charges,,,15.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,6.05,,,percent of total billed charges,,,8.27,,,percent of total billed charges,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.91,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,15.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.28,,,percent of total billed charges,,,15.97,,,percent of total billed charges,,,15.97,,,percent of total billed charges,,,,,,,,,,,,,,,15.97,,,percent of total billed charges,,,15.97,,,percent of total billed charges,,,,,,,,,15.97,,,fee schedule,,,14.86,,,percent of total billed charges,,,,,,,,,,,,,,,14.86,,,percent of total billed charges,,,14.86,,,percent of total billed charges,,,14.86,,,percent of total billed charges,,,11.98,,,percent of total billed charges,,,15.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,15.97,,,percent of total billed charges,,,15.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.21,,,percent of total billed charges,,
MELOXICAM 15 MG TAB,2500013365,CDM,637,RC,6909715912,NDC,999,EAPG,,,,outpatient,facility,15,UN,15.97,15.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MENTHOL/METHYL SALIC OINT 30GM,2500013370,CDM,637,RC,5416255501,NDC,,,,,,inpatient,facility,30,UN,2.85,2.85,0.23,2.85,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,,,,,,,2.85,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,
MENTHOL/METHYL SALIC OINT 30GM,2500013370,CDM,637,RC,5416255501,NDC,,,,,,outpatient,facility,30,UN,2.85,2.85,0.23,618.77,,1.66,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.85,,,percent of total billed charges,,,2.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.56,,,percent of total billed charges,,,,,,,,,2.85,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,2.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,2.85,,,fee schedule,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.85,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2,,,percent of total billed charges,,
MENTHOL/METHYL SALIC OINT 30GM,2500013370,CDM,637,RC,5416255501,NDC,999,EAPG,,,,outpatient,facility,30,UN,2.85,2.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEROPENEM 1 GM INJ,2500013421,CDM,636,RC,J2185,HCPCS,4456740110,NDC,,,,inpatient,facility,1,UN,118.8,118.8,9.5,118.8,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.92,,,percent of total billed charges,,,,,,,,,118.8,,,percent of total billed charges,,,65.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,61.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.42,,,percent of total billed charges,,
MEROPENEM 1 GM INJ,2500013421,CDM,636,RC,J2185,HCPCS,4456740110,NDC,,,,outpatient,facility,1,UN,118.8,118.8,0.33,618.77,,69.38,,,percent of total billed charges,,,23.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,118.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,43.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,106.92,,,percent of total billed charges,,,,,,,,,118.8,,,percent of total billed charges,,,80.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.94,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.29,,,percent of total billed charges,,,45,,,percent of total billed charges,,,61.53,,,percent of total billed charges,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,118.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,118.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.5,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,118.8,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.33,,,fee schedule,,,118.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,118.8,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,83.42,,,percent of total billed charges,,
MEROPENEM 1 GM INJ,2500013421,CDM,636,RC,J2185,HCPCS,4456740110,NDC,496,EAPG,,outpatient,facility,1,UN,118.8,118.8,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEROPENEM 500 MG VIAL,2500013424,CDM,636,RC,J2185,HCPCS,4456740010,NDC,,,,inpatient,facility,500,UN,138.01,138.01,11.04,138.01,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.21,,,percent of total billed charges,,,,,,,,,138.01,,,percent of total billed charges,,,76.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,71.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.04,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.91,,,percent of total billed charges,,
MEROPENEM 500 MG VIAL,2500013424,CDM,636,RC,J2185,HCPCS,4456740010,NDC,,,,outpatient,facility,500,UN,138.01,138.01,0.33,618.77,,80.6,,,percent of total billed charges,,,26.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,138.01,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,50.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,124.21,,,percent of total billed charges,,,,,,,,,138.01,,,percent of total billed charges,,,93.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.96,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.89,,,percent of total billed charges,,,52.28,,,percent of total billed charges,,,71.48,,,percent of total billed charges,,,,,,,,,,,,,,,27.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,138.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,138.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.04,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,138.01,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.33,,,fee schedule,,,138.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,96.91,,,percent of total billed charges,,
MEROPENEM 500 MG VIAL,2500013424,CDM,636,RC,J2185,HCPCS,4456740010,NDC,496,EAPG,,outpatient,facility,500,UN,138.01,138.01,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESALAMINE 250 MG CAPCR,2500013440,CDM,637,RC,5409218981,NDC,,,,,,inpatient,facility,250,UN,10.03,10.03,0.8,10.03,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.03,,,percent of total billed charges,,,,,,,,,10.03,,,percent of total billed charges,,,5.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,5.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.04,,,percent of total billed charges,,
MESALAMINE 250 MG CAPCR,2500013440,CDM,637,RC,5409218981,NDC,,,,,,outpatient,facility,250,UN,10.03,10.03,0.8,618.77,,5.86,,,percent of total billed charges,,,1.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.03,,,percent of total billed charges,,,8.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,8.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,8.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.03,,,percent of total billed charges,,,,,,,,,10.03,,,percent of total billed charges,,,6.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.7,,,percent of total billed charges,,,,,,,,,,,,,,,5.42,,,percent of total billed charges,,,5.42,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.23,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.62,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,5.19,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.71,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,10.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.8,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,10.03,,,fee schedule,,,9.33,,,percent of total billed charges,,,,,,,,,,,,,,,9.33,,,percent of total billed charges,,,9.33,,,percent of total billed charges,,,9.33,,,percent of total billed charges,,,7.52,,,percent of total billed charges,,,10.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.03,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.04,,,percent of total billed charges,,
MESALAMINE 250 MG CAPCR,2500013440,CDM,637,RC,5409218981,NDC,999,EAPG,,,,outpatient,facility,250,UN,10.03,10.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESALAMINE 400 MG CAPDR,2500013441,CDM,637,RC,5976201171,NDC,,,,,,inpatient,facility,400,UN,7.69,7.69,0.62,7.69,,,,,,,,,,,,,,7.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.92,,,percent of total billed charges,,,,,,,,,7.69,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.69,,,percent of total billed charges,,,,,,,,,,,,,,,7.69,,,percent of total billed charges,,,4.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,7.69,,,percent of total billed charges,,,7.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,
MESALAMINE 400 MG CAPDR,2500013441,CDM,637,RC,5976201171,NDC,,,,,,outpatient,facility,400,UN,7.69,7.69,0.62,618.77,,4.49,,,percent of total billed charges,,,1.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.69,,,percent of total billed charges,,,6.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.92,,,percent of total billed charges,,,,,,,,,7.69,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,4.15,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,7.69,,,percent of total billed charges,,,7.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.85,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,7.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.62,,,percent of total billed charges,,,7.69,,,percent of total billed charges,,,7.69,,,percent of total billed charges,,,,,,,,,,,,,,,7.69,,,percent of total billed charges,,,7.69,,,percent of total billed charges,,,,,,,,,7.69,,,fee schedule,,,7.15,,,percent of total billed charges,,,,,,,,,,,,,,,7.15,,,percent of total billed charges,,,7.15,,,percent of total billed charges,,,7.15,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,7.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.69,,,percent of total billed charges,,,7.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.4,,,percent of total billed charges,,
MESALAMINE 400 MG CAPDR,2500013441,CDM,637,RC,5976201171,NDC,999,EAPG,,,,outpatient,facility,400,UN,7.69,7.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESALAMINE 800 MG TABDR,2500013443,CDM,637,RC,6838243528,NDC,,,,,,inpatient,facility,800,UN,30.59,30.59,2.45,30.59,,,,,,,,,,,,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.53,,,percent of total billed charges,,,,,,,,,30.59,,,percent of total billed charges,,,16.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,30.59,,,percent of total billed charges,,,15.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.48,,,percent of total billed charges,,
MESALAMINE 800 MG TABDR,2500013443,CDM,637,RC,6838243528,NDC,,,,,,outpatient,facility,800,UN,30.59,30.59,2.45,618.77,,17.86,,,percent of total billed charges,,,5.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,30.59,,,percent of total billed charges,,,26.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,26.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,26.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,27.53,,,percent of total billed charges,,,,,,,,,30.59,,,percent of total billed charges,,,20.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.49,,,percent of total billed charges,,,,,,,,,,,,,,,16.52,,,percent of total billed charges,,,16.52,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.95,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,11.59,,,percent of total billed charges,,,15.84,,,percent of total billed charges,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,11.32,,,percent of total billed charges,,,11.32,,,percent of total billed charges,,,30.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.45,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,30.59,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,,,,,,,30.59,,,fee schedule,,,28.45,,,percent of total billed charges,,,,,,,,,,,,,,,28.45,,,percent of total billed charges,,,28.45,,,percent of total billed charges,,,28.45,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,30.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,30.59,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,21.48,,,percent of total billed charges,,
MESALAMINE 800 MG TABDR,2500013443,CDM,637,RC,6838243528,NDC,999,EAPG,,,,outpatient,facility,800,UN,30.59,30.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESALAMINE 1000 MG SUPP,2500013446,CDM,637,RC,3172200530,NDC,,,,,,inpatient,facility,1000,UN,138.01,138.01,11.04,138.01,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.21,,,percent of total billed charges,,,,,,,,,138.01,,,percent of total billed charges,,,76.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,71.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.04,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.91,,,percent of total billed charges,,
MESALAMINE 1000 MG SUPP,2500013446,CDM,637,RC,3172200530,NDC,,,,,,outpatient,facility,1000,UN,138.01,138.01,11.04,618.77,,80.6,,,percent of total billed charges,,,26.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,138.01,,,percent of total billed charges,,,121.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,121.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,121.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,50.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,124.21,,,percent of total billed charges,,,,,,,,,138.01,,,percent of total billed charges,,,93.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.99,,,percent of total billed charges,,,,,,,,,,,,,,,74.53,,,percent of total billed charges,,,74.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.96,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.89,,,percent of total billed charges,,,52.28,,,percent of total billed charges,,,71.48,,,percent of total billed charges,,,,,,,,,,,,,,,27.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,51.06,,,percent of total billed charges,,,51.06,,,percent of total billed charges,,,138.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,138.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.04,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,138.01,,,fee schedule,,,128.38,,,percent of total billed charges,,,,,,,,,,,,,,,128.38,,,percent of total billed charges,,,128.38,,,percent of total billed charges,,,128.38,,,percent of total billed charges,,,103.51,,,percent of total billed charges,,,138.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,96.91,,,percent of total billed charges,,
MESALAMINE 1000 MG SUPP,2500013446,CDM,637,RC,3172200530,NDC,999,EAPG,,,,outpatient,facility,1000,UN,138.01,138.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESALAMINE ENEMA 4 GM/60 ML,2500013449,CDM,637,RC,4580209851,NDC,,,,,,inpatient,facility,60,UN,80.16,80.16,6.41,80.16,,,,,,,,,,,,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.14,,,percent of total billed charges,,,,,,,,,80.16,,,percent of total billed charges,,,44.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,80.16,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.41,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.29,,,percent of total billed charges,,
MESALAMINE ENEMA 4 GM/60 ML,2500013449,CDM,637,RC,4580209851,NDC,,,,,,outpatient,facility,60,UN,80.16,80.16,6.41,618.77,,46.81,,,percent of total billed charges,,,15.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,80.16,,,percent of total billed charges,,,70.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,70.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,70.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,29.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,72.14,,,percent of total billed charges,,,,,,,,,80.16,,,percent of total billed charges,,,54.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.56,,,percent of total billed charges,,,,,,,,,,,,,,,43.29,,,percent of total billed charges,,,43.29,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.8,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.92,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,41.51,,,percent of total billed charges,,,,,,,,,,,,,,,16.03,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,29.66,,,percent of total billed charges,,,29.66,,,percent of total billed charges,,,80.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,80.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.41,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,80.16,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,,,,,,,80.16,,,fee schedule,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,74.56,,,percent of total billed charges,,,74.56,,,percent of total billed charges,,,60.12,,,percent of total billed charges,,,80.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,80.16,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.08,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,56.29,,,percent of total billed charges,,
MESALAMINE ENEMA 4 GM/60 ML,2500013449,CDM,637,RC,4580209851,NDC,999,EAPG,,,,outpatient,facility,60,UN,80.16,80.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METFORMIN HCL 500 MG TAB,2500013490,CDM,637,RC,7278919290,NDC,,,,,,inpatient,facility,500,UN,0.39,0.39,0.03,0.39,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,
METFORMIN HCL 500 MG TAB,2500013490,CDM,637,RC,7278919290,NDC,,,,,,outpatient,facility,500,UN,0.39,0.39,0.03,618.77,,0.23,,,percent of total billed charges,,,0.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.39,,,percent of total billed charges,,,0.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.35,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.14,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,0.39,,,fee schedule,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.27,,,percent of total billed charges,,
METFORMIN HCL 500 MG TAB,2500013490,CDM,637,RC,7278919290,NDC,999,EAPG,,,,outpatient,facility,500,UN,0.39,0.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METFORMIN HCL 850 MG TAB,2500013493,CDM,637,RC,3535692290,NDC,,,,,,inpatient,facility,850,UN,4.72,4.72,0.38,4.72,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.25,,,percent of total billed charges,,,,,,,,,4.72,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,
METFORMIN HCL 850 MG TAB,2500013493,CDM,637,RC,3535692290,NDC,,,,,,outpatient,facility,850,UN,4.72,4.72,0.38,618.77,,2.76,,,percent of total billed charges,,,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.72,,,percent of total billed charges,,,4.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.25,,,percent of total billed charges,,,,,,,,,4.72,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.62,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.59,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,4.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.38,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,4.72,,,fee schedule,,,4.39,,,percent of total billed charges,,,,,,,,,,,,,,,4.39,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,4.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.31,,,percent of total billed charges,,
METFORMIN HCL 850 MG TAB,2500013493,CDM,637,RC,3535692290,NDC,999,EAPG,,,,outpatient,facility,850,UN,4.72,4.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHADONE ORAL 10 MG TAB,2500013510,CDM,637,RC,904653061,NDC,,,,,,inpatient,facility,10,UN,0.82,0.82,0.07,0.82,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
METHADONE ORAL 10 MG TAB,2500013510,CDM,637,RC,904653061,NDC,,,,,,outpatient,facility,10,UN,0.82,0.82,0.07,618.77,,0.48,,,percent of total billed charges,,,0.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.82,,,percent of total billed charges,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.74,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,0.82,,,fee schedule,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.58,,,percent of total billed charges,,
METHADONE ORAL 10 MG TAB,2500013510,CDM,637,RC,904653061,NDC,999,EAPG,,,,outpatient,facility,10,UN,0.82,0.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHADONE ORAL 5 MG TAB,2500013512,CDM,637,RC,406575562,NDC,,,,,,inpatient,facility,5,UN,1.52,1.52,0.12,1.52,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,
METHADONE ORAL 5 MG TAB,2500013512,CDM,637,RC,406575562,NDC,,,,,,outpatient,facility,5,UN,1.52,1.52,0.12,618.77,,0.89,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.52,,,percent of total billed charges,,,1.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.37,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,1.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,1.52,,,fee schedule,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,1.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.07,,,percent of total billed charges,,
METHADONE ORAL 5 MG TAB,2500013512,CDM,637,RC,406575562,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.52,1.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHAZOLAMIDE 50 MG TAB,2500013523,CDM,637,RC,574079101,NDC,,,,,,inpatient,facility,50,UN,15.18,15.18,1.21,15.18,,,,,,,,,,,,,,15.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,,,,,,,15.18,,,percent of total billed charges,,,8.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.18,,,percent of total billed charges,,,,,,,,,,,,,,,15.18,,,percent of total billed charges,,,7.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,15.18,,,percent of total billed charges,,,15.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.66,,,percent of total billed charges,,
METHAZOLAMIDE 50 MG TAB,2500013523,CDM,637,RC,574079101,NDC,,,,,,outpatient,facility,50,UN,15.18,15.18,1.21,618.77,,8.87,,,percent of total billed charges,,,2.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,15.18,,,percent of total billed charges,,,13.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,13.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,13.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.66,,,percent of total billed charges,,,,,,,,,15.18,,,percent of total billed charges,,,10.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.66,,,percent of total billed charges,,,,,,,,,,,,,,,8.2,,,percent of total billed charges,,,8.2,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,15.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.91,,,percent of total billed charges,,,15.18,,,percent of total billed charges,,,15.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.54,,,percent of total billed charges,,,5.75,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.62,,,percent of total billed charges,,,5.62,,,percent of total billed charges,,,15.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.21,,,percent of total billed charges,,,15.18,,,percent of total billed charges,,,15.18,,,percent of total billed charges,,,,,,,,,,,,,,,15.18,,,percent of total billed charges,,,15.18,,,percent of total billed charges,,,,,,,,,15.18,,,fee schedule,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,11.38,,,percent of total billed charges,,,15.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,15.18,,,percent of total billed charges,,,15.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.66,,,percent of total billed charges,,
METHAZOLAMIDE 50 MG TAB,2500013523,CDM,637,RC,574079101,NDC,999,EAPG,,,,outpatient,facility,50,UN,15.18,15.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHENAMINE HIPPURATE 1 GM TAB,2500013540,CDM,637,RC,6586278201,NDC,,,,,,inpatient,facility,1,UN,6.9,6.9,0.55,6.9,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.21,,,percent of total billed charges,,,,,,,,,6.9,,,percent of total billed charges,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.85,,,percent of total billed charges,,
METHENAMINE HIPPURATE 1 GM TAB,2500013540,CDM,637,RC,6586278201,NDC,,,,,,outpatient,facility,1,UN,6.9,6.9,0.55,618.77,,4.03,,,percent of total billed charges,,,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.9,,,percent of total billed charges,,,6.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.21,,,percent of total billed charges,,,,,,,,,6.9,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.3,,,percent of total billed charges,,,,,,,,,,,,,,,3.73,,,percent of total billed charges,,,3.73,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.6,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.24,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,3.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,6.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.55,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,,,,,,,6.9,,,fee schedule,,,6.42,,,percent of total billed charges,,,,,,,,,,,,,,,6.42,,,percent of total billed charges,,,6.42,,,percent of total billed charges,,,6.42,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,6.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.9,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.85,,,percent of total billed charges,,
METHENAMINE HIPPURATE 1 GM TAB,2500013540,CDM,637,RC,6586278201,NDC,999,EAPG,,,,outpatient,facility,1,UN,6.9,6.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHIMAZOLE 5 MG TAB,2500013562,CDM,637,RC,2315507001,NDC,,,,,,inpatient,facility,5,UN,1.45,1.45,0.12,1.45,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,
METHIMAZOLE 5 MG TAB,2500013562,CDM,637,RC,2315507001,NDC,,,,,,outpatient,facility,5,UN,1.45,1.45,0.12,618.77,,0.85,,,percent of total billed charges,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.45,,,percent of total billed charges,,,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.3,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.54,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,1.45,,,fee schedule,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.02,,,percent of total billed charges,,
METHIMAZOLE 5 MG TAB,2500013562,CDM,637,RC,2315507001,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.45,1.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHOCARBAMOL 500 MG TAB,2500013572,CDM,637,RC,7001075401,NDC,,,,,,inpatient,facility,500,UN,1.68,1.68,0.13,1.68,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
METHOCARBAMOL 500 MG TAB,2500013572,CDM,637,RC,7001075401,NDC,,,,,,outpatient,facility,500,UN,1.68,1.68,0.13,618.77,,0.98,,,percent of total billed charges,,,0.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.68,,,percent of total billed charges,,,1.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.51,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,1.68,,,fee schedule,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.18,,,percent of total billed charges,,
METHOCARBAMOL 500 MG TAB,2500013572,CDM,637,RC,7001075401,NDC,999,EAPG,,,,outpatient,facility,500,UN,1.68,1.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHOHEXITAL  SOD 500 MG INJ,2500013580,CDM,250,RC,J3490,HCPCS,4202310501,NDC,,,,inpatient,facility,500,UN,283.54,283.54,22.68,283.54,,,,,,,,,,,,,,283.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.19,,,percent of total billed charges,,,,,,,,,283.54,,,percent of total billed charges,,,156.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.54,,,percent of total billed charges,,,,,,,,,,,,,,,283.54,,,percent of total billed charges,,,147.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.68,,,percent of total billed charges,,,283.54,,,percent of total billed charges,,,283.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,283.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.1,,,percent of total billed charges,,
METHOHEXITAL  SOD 500 MG INJ,2500013580,CDM,250,RC,J3490,HCPCS,4202310501,NDC,,,,outpatient,facility,500,UN,283.54,283.54,1.2,618.77,,165.59,,,percent of total billed charges,,,55.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,283.54,,,percent of total billed charges,,,249.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,249.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,249.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,283.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,103.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,255.19,,,percent of total billed charges,,,,,,,,,283.54,,,percent of total billed charges,,,192.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.76,,,percent of total billed charges,,,,,,,,,,,,,,,283.54,,,percent of total billed charges,,,283.54,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,283.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,147.84,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.49,,,percent of total billed charges,,,107.4,,,percent of total billed charges,,,146.85,,,percent of total billed charges,,,,,,,,,,,,,,,56.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,283.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,283.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.68,,,percent of total billed charges,,,283.54,,,percent of total billed charges,,,283.54,,,percent of total billed charges,,,,,,,,,,,,,,,283.54,,,percent of total billed charges,,,283.54,,,percent of total billed charges,,,,,,,,,283.54,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,212.66,,,percent of total billed charges,,,283.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,283.54,,,percent of total billed charges,,,283.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,199.1,,,percent of total billed charges,,
METHOHEXITAL  SOD 500 MG INJ,2500013580,CDM,250,RC,J3490,HCPCS,4202310501,NDC,435,EAPG,,outpatient,facility,500,UN,283.54,283.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHOHEXITAL SODIUM 100 MG INJ,2500013585,CDM,250,RC,J3490,HCPCS,4202310501,NDC,,,,inpatient,facility,10,UN,57.95,57.95,4.64,57.95,,,,,,,,,,,,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.16,,,percent of total billed charges,,,,,,,,,57.95,,,percent of total billed charges,,,32.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,57.95,,,percent of total billed charges,,,30.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.64,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.69,,,percent of total billed charges,,
METHOHEXITAL SODIUM 100 MG INJ,2500013585,CDM,250,RC,J3490,HCPCS,4202310501,NDC,,,,outpatient,facility,10,UN,57.95,57.95,1.2,618.77,,33.84,,,percent of total billed charges,,,11.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,57.95,,,percent of total billed charges,,,51.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,51.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,51.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,21.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,52.16,,,percent of total billed charges,,,,,,,,,57.95,,,percent of total billed charges,,,39.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.51,,,percent of total billed charges,,,,,,,,,,,,,,,57.95,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.22,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.04,,,percent of total billed charges,,,21.95,,,percent of total billed charges,,,30.01,,,percent of total billed charges,,,,,,,,,,,,,,,11.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,57.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,57.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.64,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,57.95,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,57.95,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,43.46,,,percent of total billed charges,,,57.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,57.95,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,40.69,,,percent of total billed charges,,
METHOHEXITAL SODIUM 100 MG INJ,2500013585,CDM,250,RC,J3490,HCPCS,4202310501,NDC,435,EAPG,,outpatient,facility,10,UN,57.95,57.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPHENIDATE 10 MG TAB,2500013660,CDM,637,RC,6808482321,NDC,,,,,,inpatient,facility,10,UN,6.56,6.56,0.52,6.56,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.9,,,percent of total billed charges,,,,,,,,,6.56,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,3.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.61,,,percent of total billed charges,,
METHYLPHENIDATE 10 MG TAB,2500013660,CDM,637,RC,6808482321,NDC,,,,,,outpatient,facility,10,UN,6.56,6.56,0.52,618.77,,3.83,,,percent of total billed charges,,,1.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.56,,,percent of total billed charges,,,5.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.9,,,percent of total billed charges,,,,,,,,,6.56,,,percent of total billed charges,,,4.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.04,,,percent of total billed charges,,,,,,,,,,,,,,,3.54,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.42,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.99,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.43,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,6.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.52,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,6.56,,,fee schedule,,,6.1,,,percent of total billed charges,,,,,,,,,,,,,,,6.1,,,percent of total billed charges,,,6.1,,,percent of total billed charges,,,6.1,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,6.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.61,,,percent of total billed charges,,
METHYLPHENIDATE 10 MG TAB,2500013660,CDM,637,RC,6808482321,NDC,999,EAPG,,,,outpatient,facility,10,UN,6.56,6.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPHENIDATE 5 MG TAB,2500013664,CDM,637,RC,1070210001,NDC,,,,,,inpatient,facility,5,UN,2.38,2.38,0.19,2.38,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,2.38,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,
METHYLPHENIDATE 5 MG TAB,2500013664,CDM,637,RC,1070210001,NDC,,,,,,outpatient,facility,5,UN,2.38,2.38,0.19,618.77,,1.39,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.38,,,percent of total billed charges,,,2.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.14,,,percent of total billed charges,,,,,,,,,2.38,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,0.9,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.88,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,2.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,2.38,,,fee schedule,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,2.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.67,,,percent of total billed charges,,
METHYLPHENIDATE 5 MG TAB,2500013664,CDM,637,RC,1070210001,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.38,2.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPHENIDATE 18 MG TABCR,2500013666,CDM,637,RC,3172295201,NDC,,,,,,inpatient,facility,18,UN,43.59,43.59,3.49,43.59,,,,,,,,,,,,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.23,,,percent of total billed charges,,,,,,,,,43.59,,,percent of total billed charges,,,24.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,43.59,,,percent of total billed charges,,,22.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.61,,,percent of total billed charges,,
METHYLPHENIDATE 18 MG TABCR,2500013666,CDM,637,RC,3172295201,NDC,,,,,,outpatient,facility,18,UN,43.59,43.59,3.49,618.77,,25.46,,,percent of total billed charges,,,8.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,43.59,,,percent of total billed charges,,,38.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,38.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,38.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,15.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,39.23,,,percent of total billed charges,,,,,,,,,43.59,,,percent of total billed charges,,,29.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.48,,,percent of total billed charges,,,,,,,,,,,,,,,23.54,,,percent of total billed charges,,,23.54,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.73,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.13,,,percent of total billed charges,,,16.51,,,percent of total billed charges,,,22.58,,,percent of total billed charges,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,16.13,,,percent of total billed charges,,,16.13,,,percent of total billed charges,,,43.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.49,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,43.59,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,,,,,,,43.59,,,fee schedule,,,40.55,,,percent of total billed charges,,,,,,,,,,,,,,,40.55,,,percent of total billed charges,,,40.55,,,percent of total billed charges,,,40.55,,,percent of total billed charges,,,32.69,,,percent of total billed charges,,,43.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,43.59,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,30.61,,,percent of total billed charges,,
METHYLPHENIDATE 18 MG TABCR,2500013666,CDM,637,RC,3172295201,NDC,999,EAPG,,,,outpatient,facility,18,UN,43.59,43.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPREDNISOLONE 4MG TAB,2500013670,CDM,637,RC,J7509,HCPCS,5974600106,NDC,,,,inpatient,facility,4,UN,5.44,5.44,0.44,5.44,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.9,,,percent of total billed charges,,,,,,,,,5.44,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,
METHYLPREDNISOLONE 4MG TAB,2500013670,CDM,637,RC,J7509,HCPCS,5974600106,NDC,,,,outpatient,facility,4,UN,5.44,5.44,0.25,618.77,,3.18,,,percent of total billed charges,,,1.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.44,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.9,,,percent of total billed charges,,,,,,,,,5.44,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,2.82,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,5.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.44,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,,,,,,,5.44,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.25,,,fee schedule,,,5.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.44,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.82,,,percent of total billed charges,,
METHYLPREDNISOLONE 4MG TAB,2500013670,CDM,637,RC,J7509,HCPCS,5974600106,NDC,496,EAPG,,outpatient,facility,4,UN,5.44,5.44,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOCLOPRAMIDE 10 MG TAB,2500013700,CDM,637,RC,J8597,HCPCS,5107988820,NDC,,,,inpatient,facility,10,UN,3.17,3.17,0.25,3.17,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,
METOCLOPRAMIDE 10 MG TAB,2500013700,CDM,637,RC,J8597,HCPCS,5107988820,NDC,,,,outpatient,facility,10,UN,3.17,3.17,0.25,618.77,,1.85,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.85,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.25,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,3.17,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.38,,,percent of total billed charges,,,3.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.23,,,percent of total billed charges,,
METOCLOPRAMIDE 10 MG TAB,2500013700,CDM,637,RC,J8597,HCPCS,5107988820,NDC,999,EAPG,,outpatient,facility,10,UN,3.17,3.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOCLOPRAMIDE 5 MG/5 ML 10 ML,2500013706,CDM,637,RC,J8597,HCPCS,121157610,NDC,,,,inpatient,facility,10,UN,16.04,16.04,1.28,16.04,,,,,,,,,,,,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.44,,,percent of total billed charges,,,,,,,,,16.04,,,percent of total billed charges,,,8.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,16.04,,,percent of total billed charges,,,8.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.26,,,percent of total billed charges,,
METOCLOPRAMIDE 5 MG/5 ML 10 ML,2500013706,CDM,637,RC,J8597,HCPCS,121157610,NDC,,,,outpatient,facility,10,UN,16.04,16.04,1.28,618.77,,9.37,,,percent of total billed charges,,,3.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,14.44,,,percent of total billed charges,,,,,,,,,16.04,,,percent of total billed charges,,,10.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.36,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.19,,,percent of total billed charges,,,6.08,,,percent of total billed charges,,,8.31,,,percent of total billed charges,,,,,,,,,,,,,,,3.21,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,16.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.28,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,16.04,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,,,,,,,16.04,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,12.03,,,percent of total billed charges,,,16.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.04,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.26,,,percent of total billed charges,,
METOCLOPRAMIDE 5 MG/5 ML 10 ML,2500013706,CDM,637,RC,J8597,HCPCS,121157610,NDC,999,EAPG,,outpatient,facility,10,UN,16.04,16.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOLAZONE 2.5 MG TAB,2500013722,CDM,637,RC,185505001,NDC,,,,,,inpatient,facility,2.5,UN,6.83,6.83,0.55,6.83,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.15,,,percent of total billed charges,,,,,,,,,6.83,,,percent of total billed charges,,,3.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.8,,,percent of total billed charges,,
METOLAZONE 2.5 MG TAB,2500013722,CDM,637,RC,185505001,NDC,,,,,,outpatient,facility,2.5,UN,6.83,6.83,0.55,618.77,,3.99,,,percent of total billed charges,,,1.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.83,,,percent of total billed charges,,,6.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.15,,,percent of total billed charges,,,,,,,,,6.83,,,percent of total billed charges,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.25,,,percent of total billed charges,,,,,,,,,,,,,,,3.69,,,percent of total billed charges,,,3.69,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.19,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.53,,,percent of total billed charges,,,2.53,,,percent of total billed charges,,,6.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.55,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,,,,,,,6.83,,,fee schedule,,,6.35,,,percent of total billed charges,,,,,,,,,,,,,,,6.35,,,percent of total billed charges,,,6.35,,,percent of total billed charges,,,6.35,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,6.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.83,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.8,,,percent of total billed charges,,
METOLAZONE 2.5 MG TAB,2500013722,CDM,637,RC,185505001,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,6.83,6.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOPROLOL SUCC 100 MG TABCR,2500013735,CDM,637,RC,4596367796,NDC,,,,,,inpatient,facility,100,UN,5.21,5.21,0.42,5.21,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.69,,,percent of total billed charges,,,,,,,,,5.21,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.66,,,percent of total billed charges,,
METOPROLOL SUCC 100 MG TABCR,2500013735,CDM,637,RC,4596367796,NDC,,,,,,outpatient,facility,100,UN,5.21,5.21,0.42,618.77,,3.04,,,percent of total billed charges,,,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.21,,,percent of total billed charges,,,4.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.69,,,percent of total billed charges,,,,,,,,,5.21,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4,,,percent of total billed charges,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.93,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,5.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.42,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,,,,,,,5.21,,,fee schedule,,,4.85,,,percent of total billed charges,,,,,,,,,,,,,,,4.85,,,percent of total billed charges,,,4.85,,,percent of total billed charges,,,4.85,,,percent of total billed charges,,,3.91,,,percent of total billed charges,,,5.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.21,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.66,,,percent of total billed charges,,
METOPROLOL SUCC 100 MG TABCR,2500013735,CDM,637,RC,4596367796,NDC,999,EAPG,,,,outpatient,facility,100,UN,5.21,5.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOPROLOL SUCC 50 MG TABCR,2500013736,CDM,637,RC,4596367696,NDC,,,,,,inpatient,facility,50,UN,3.47,3.47,0.28,3.47,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,,,,,,,3.47,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.44,,,percent of total billed charges,,
METOPROLOL SUCC 50 MG TABCR,2500013736,CDM,637,RC,4596367696,NDC,,,,,,outpatient,facility,50,UN,3.47,3.47,0.28,618.77,,2.03,,,percent of total billed charges,,,0.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.47,,,percent of total billed charges,,,3.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.12,,,percent of total billed charges,,,,,,,,,3.47,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.66,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.28,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,3.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,,,,,,,3.47,,,fee schedule,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,3.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.47,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.44,,,percent of total billed charges,,
METOPROLOL SUCC 50 MG TABCR,2500013736,CDM,637,RC,4596367696,NDC,999,EAPG,,,,outpatient,facility,50,UN,3.47,3.47,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOPROLOL TART 5 MG/5 ML AMP,2500013740,CDM,250,RC,J3490,HCPCS,7261174010,NDC,,,,inpatient,facility,5,UN,3.89,3.89,0.31,3.89,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,3.89,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,
METOPROLOL TART 5 MG/5 ML AMP,2500013740,CDM,250,RC,J3490,HCPCS,7261174010,NDC,,,,outpatient,facility,5,UN,3.89,3.89,0.31,618.77,,2.27,,,percent of total billed charges,,,0.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.89,,,percent of total billed charges,,,3.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.5,,,percent of total billed charges,,,,,,,,,3.89,,,percent of total billed charges,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,3.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.31,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,3.89,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.92,,,percent of total billed charges,,,3.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.89,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.73,,,percent of total billed charges,,
METOPROLOL TART 5 MG/5 ML AMP,2500013740,CDM,250,RC,J3490,HCPCS,7261174010,NDC,435,EAPG,,outpatient,facility,5,UN,3.89,3.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOPROLOL TART 50 MG TAB,2500013745,CDM,637,RC,5107980120,NDC,,,,,,inpatient,facility,50,UN,1.88,1.88,0.15,1.88,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,
METOPROLOL TART 50 MG TAB,2500013745,CDM,637,RC,5107980120,NDC,,,,,,outpatient,facility,50,UN,1.88,1.88,0.15,618.77,,1.1,,,percent of total billed charges,,,0.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.88,,,percent of total billed charges,,,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.69,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.7,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,1.88,,,fee schedule,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.32,,,percent of total billed charges,,
METOPROLOL TART 50 MG TAB,2500013745,CDM,637,RC,5107980120,NDC,999,EAPG,,,,outpatient,facility,50,UN,1.88,1.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOPROLOL TART 25 MG TAB,2500013748,CDM,637,RC,5107925520,NDC,,,,,,inpatient,facility,25,UN,0.79,0.79,0.06,0.79,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,
METOPROLOL TART 25 MG TAB,2500013748,CDM,637,RC,5107925520,NDC,,,,,,outpatient,facility,25,UN,0.79,0.79,0.06,618.77,,0.46,,,percent of total billed charges,,,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.71,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,0.79,,,fee schedule,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.55,,,percent of total billed charges,,
METOPROLOL TART 25 MG TAB,2500013748,CDM,637,RC,5107925520,NDC,999,EAPG,,,,outpatient,facility,25,UN,0.79,0.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METRONIDAZOLE 0.75   70GM VAG,2500013760,CDM,637,RC,245086070,NDC,,,,,,inpatient,facility,70,UN,538.03,538.03,43.04,538.03,,,,,,,,,,,,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,484.23,,,percent of total billed charges,,,,,,,,,538.03,,,percent of total billed charges,,,297.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,538.03,,,percent of total billed charges,,,280.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.04,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.8,,,percent of total billed charges,,
METRONIDAZOLE 0.75   70GM VAG,2500013760,CDM,637,RC,245086070,NDC,,,,,,outpatient,facility,70,UN,538.03,538.03,43.04,618.77,,314.21,,,percent of total billed charges,,,104.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,538.03,,,percent of total billed charges,,,473.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,473.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,473.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,196.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,484.23,,,percent of total billed charges,,,,,,,,,538.03,,,percent of total billed charges,,,364.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,413.21,,,percent of total billed charges,,,,,,,,,,,,,,,290.54,,,percent of total billed charges,,,290.54,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,280.53,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,408.9,,,percent of total billed charges,,,203.81,,,percent of total billed charges,,,278.65,,,percent of total billed charges,,,,,,,,,,,,,,,107.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,199.07,,,percent of total billed charges,,,199.07,,,percent of total billed charges,,,538.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,538.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.04,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,538.03,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,,,,,,,538.03,,,fee schedule,,,500.48,,,percent of total billed charges,,,,,,,,,,,,,,,500.48,,,percent of total billed charges,,,500.48,,,percent of total billed charges,,,500.48,,,percent of total billed charges,,,403.52,,,percent of total billed charges,,,538.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,538.03,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,269.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,377.8,,,percent of total billed charges,,
METRONIDAZOLE 0.75   70GM VAG,2500013760,CDM,637,RC,245086070,NDC,999,EAPG,,,,outpatient,facility,70,UN,538.03,538.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METRONIDAZOLE 250 MG 50 ML IV,2500013763,CDM,250,RC,J3490,HCPCS,409781124,NDC,,,,inpatient,facility,50,UN,3.17,3.17,0.25,3.17,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,
METRONIDAZOLE 250 MG 50 ML IV,2500013763,CDM,250,RC,J3490,HCPCS,409781124,NDC,,,,outpatient,facility,50,UN,3.17,3.17,0.25,618.77,,1.85,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.17,,,percent of total billed charges,,,2.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.85,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.25,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,3.17,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.38,,,percent of total billed charges,,,3.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.23,,,percent of total billed charges,,
METRONIDAZOLE 250 MG 50 ML IV,2500013763,CDM,250,RC,J3490,HCPCS,409781124,NDC,435,EAPG,,outpatient,facility,50,UN,3.17,3.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METRONIDAZOLE 500 MG TAB,2500013766,CDM,637,RC,2315565201,NDC,,,,,,inpatient,facility,500,UN,2.41,2.41,0.19,2.41,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,2.41,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,
METRONIDAZOLE 500 MG TAB,2500013766,CDM,637,RC,2315565201,NDC,,,,,,outpatient,facility,500,UN,2.41,2.41,0.19,618.77,,1.41,,,percent of total billed charges,,,0.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.41,,,percent of total billed charges,,,2.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.17,,,percent of total billed charges,,,,,,,,,2.41,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.89,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,2.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,2.41,,,fee schedule,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,2.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.69,,,percent of total billed charges,,
METRONIDAZOLE 500 MG TAB,2500013766,CDM,637,RC,2315565201,NDC,999,EAPG,,,,outpatient,facility,500,UN,2.41,2.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METRONIDAZOLE 500 MG/100 ML,2500013769,CDM,250,RC,J3490,HCPCS,409781124,NDC,,,,inpatient,facility,100,UN,6.34,6.34,0.51,6.34,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.71,,,percent of total billed charges,,,,,,,,,6.34,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,
METRONIDAZOLE 500 MG/100 ML,2500013769,CDM,250,RC,J3490,HCPCS,409781124,NDC,,,,outpatient,facility,100,UN,6.34,6.34,0.51,618.77,,3.7,,,percent of total billed charges,,,1.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.34,,,percent of total billed charges,,,5.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.71,,,percent of total billed charges,,,,,,,,,6.34,,,percent of total billed charges,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.87,,,percent of total billed charges,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.82,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,6.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.51,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,6.34,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.75,,,percent of total billed charges,,,6.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.45,,,percent of total billed charges,,
METRONIDAZOLE 500 MG/100 ML,2500013769,CDM,250,RC,J3490,HCPCS,409781124,NDC,435,EAPG,,outpatient,facility,100,UN,6.34,6.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEXILETINE HCL 150 MG CAP,2500013770,CDM,637,RC,93873901,NDC,,,,,,inpatient,facility,150,UN,8.38,8.38,0.67,8.38,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.54,,,percent of total billed charges,,,,,,,,,8.38,,,percent of total billed charges,,,4.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.88,,,percent of total billed charges,,
MEXILETINE HCL 150 MG CAP,2500013770,CDM,637,RC,93873901,NDC,,,,,,outpatient,facility,150,UN,8.38,8.38,0.67,618.77,,4.89,,,percent of total billed charges,,,1.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.38,,,percent of total billed charges,,,7.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.54,,,percent of total billed charges,,,,,,,,,8.38,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.44,,,percent of total billed charges,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,4.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.37,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,4.34,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,8.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.67,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,,,,,,,8.38,,,fee schedule,,,7.8,,,percent of total billed charges,,,,,,,,,,,,,,,7.8,,,percent of total billed charges,,,7.8,,,percent of total billed charges,,,7.8,,,percent of total billed charges,,,6.29,,,percent of total billed charges,,,8.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.38,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.88,,,percent of total billed charges,,
MEXILETINE HCL 150 MG CAP,2500013770,CDM,637,RC,93873901,NDC,999,EAPG,,,,outpatient,facility,150,UN,8.38,8.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MICONAZOLE  2  71 GM PWD,2500013796,CDM,637,RC,7000003231,NDC,,,,,,inpatient,facility,71,UN,18.1,18.1,1.45,18.1,,,,,,,,,,,,,,18.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.29,,,percent of total billed charges,,,,,,,,,18.1,,,percent of total billed charges,,,10.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.1,,,percent of total billed charges,,,,,,,,,,,,,,,18.1,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,18.1,,,percent of total billed charges,,,18.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.71,,,percent of total billed charges,,
MICONAZOLE  2  71 GM PWD,2500013796,CDM,637,RC,7000003231,NDC,,,,,,outpatient,facility,71,UN,18.1,18.1,1.45,618.77,,10.57,,,percent of total billed charges,,,3.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,18.1,,,percent of total billed charges,,,15.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,15.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,15.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,16.29,,,percent of total billed charges,,,,,,,,,18.1,,,percent of total billed charges,,,12.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.9,,,percent of total billed charges,,,,,,,,,,,,,,,9.77,,,percent of total billed charges,,,9.77,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,18.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,18.1,,,percent of total billed charges,,,18.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,9.37,,,percent of total billed charges,,,,,,,,,,,,,,,3.62,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.7,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,18.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.45,,,percent of total billed charges,,,18.1,,,percent of total billed charges,,,18.1,,,percent of total billed charges,,,,,,,,,,,,,,,18.1,,,percent of total billed charges,,,18.1,,,percent of total billed charges,,,,,,,,,18.1,,,fee schedule,,,16.84,,,percent of total billed charges,,,,,,,,,,,,,,,16.84,,,percent of total billed charges,,,16.84,,,percent of total billed charges,,,16.84,,,percent of total billed charges,,,13.58,,,percent of total billed charges,,,18.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,18.1,,,percent of total billed charges,,,18.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,12.71,,,percent of total billed charges,,
MICONAZOLE  2  71 GM PWD,2500013796,CDM,637,RC,7000003231,NDC,999,EAPG,,,,outpatient,facility,71,UN,18.1,18.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIDODRINE 5 MG TAB,2500013832,CDM,637,RC,904681861,NDC,,,,,,inpatient,facility,5,UN,2.87,2.87,0.23,2.87,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,,,,,,,2.87,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,
MIDODRINE 5 MG TAB,2500013832,CDM,637,RC,904681861,NDC,,,,,,outpatient,facility,5,UN,2.87,2.87,0.23,618.77,,1.68,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.87,,,percent of total billed charges,,,2.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.58,,,percent of total billed charges,,,,,,,,,2.87,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.06,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,2.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,2.87,,,fee schedule,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.02,,,percent of total billed charges,,
MIDODRINE 5 MG TAB,2500013832,CDM,637,RC,904681861,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.87,2.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MINERAL OIL ENEMA 133 ML,2500013875,CDM,637,RC,7000001091,NDC,,,,,,inpatient,facility,133,UN,4.19,4.19,0.34,4.19,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.77,,,percent of total billed charges,,,,,,,,,4.19,,,percent of total billed charges,,,2.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,
MINERAL OIL ENEMA 133 ML,2500013875,CDM,637,RC,7000001091,NDC,,,,,,outpatient,facility,133,UN,4.19,4.19,0.34,618.77,,2.45,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.19,,,percent of total billed charges,,,3.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.77,,,percent of total billed charges,,,,,,,,,4.19,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,2.26,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.18,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,4.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.34,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,4.19,,,fee schedule,,,3.9,,,percent of total billed charges,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,3.9,,,percent of total billed charges,,,3.9,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,4.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.94,,,percent of total billed charges,,
MINERAL OIL ENEMA 133 ML,2500013875,CDM,637,RC,7000001091,NDC,999,EAPG,,,,outpatient,facility,133,UN,4.19,4.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MINERAL OIL LIGHT 10 ML UD,2500013883,CDM,637,RC,6332325410,NDC,,,,,,inpatient,facility,10,UN,29.97,29.97,2.4,29.97,,,,,,,,,,,,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.97,,,percent of total billed charges,,,,,,,,,29.97,,,percent of total billed charges,,,16.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,29.97,,,percent of total billed charges,,,15.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.04,,,percent of total billed charges,,
MINERAL OIL LIGHT 10 ML UD,2500013883,CDM,637,RC,6332325410,NDC,,,,,,outpatient,facility,10,UN,29.97,29.97,2.4,618.77,,17.5,,,percent of total billed charges,,,5.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,29.97,,,percent of total billed charges,,,26.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,26.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,26.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26.97,,,percent of total billed charges,,,,,,,,,29.97,,,percent of total billed charges,,,20.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.02,,,percent of total billed charges,,,,,,,,,,,,,,,16.18,,,percent of total billed charges,,,16.18,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.63,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.78,,,percent of total billed charges,,,11.35,,,percent of total billed charges,,,15.52,,,percent of total billed charges,,,,,,,,,,,,,,,5.99,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,11.09,,,percent of total billed charges,,,11.09,,,percent of total billed charges,,,29.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.4,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,29.97,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,,,,,,,29.97,,,fee schedule,,,27.88,,,percent of total billed charges,,,,,,,,,,,,,,,27.88,,,percent of total billed charges,,,27.88,,,percent of total billed charges,,,27.88,,,percent of total billed charges,,,22.48,,,percent of total billed charges,,,29.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,29.97,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,21.04,,,percent of total billed charges,,
MINERAL OIL LIGHT 10 ML UD,2500013883,CDM,637,RC,6332325410,NDC,999,EAPG,,,,outpatient,facility,10,UN,29.97,29.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MINOCYCLINE HCL 50 MG CAP,2500013892,CDM,637,RC,6838231601,NDC,,,,,,inpatient,facility,50,UN,5.61,5.61,0.45,5.61,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.05,,,percent of total billed charges,,,,,,,,,5.61,,,percent of total billed charges,,,3.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.94,,,percent of total billed charges,,
MINOCYCLINE HCL 50 MG CAP,2500013892,CDM,637,RC,6838231601,NDC,,,,,,outpatient,facility,50,UN,5.61,5.61,0.45,618.77,,3.28,,,percent of total billed charges,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.61,,,percent of total billed charges,,,4.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.05,,,percent of total billed charges,,,,,,,,,5.61,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.31,,,percent of total billed charges,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,5.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.45,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,5.61,,,fee schedule,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,5.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.94,,,percent of total billed charges,,
MINOCYCLINE HCL 50 MG CAP,2500013892,CDM,637,RC,6838231601,NDC,999,EAPG,,,,outpatient,facility,50,UN,5.61,5.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MINOXIDIL 10 MG TAB,2500013900,CDM,637,RC,6808420501,NDC,,,,,,inpatient,facility,10,UN,6.99,6.99,0.56,6.99,,,,,,,,,,,,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.29,,,percent of total billed charges,,,,,,,,,6.99,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,6.99,,,percent of total billed charges,,,3.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,
MINOXIDIL 10 MG TAB,2500013900,CDM,637,RC,6808420501,NDC,,,,,,outpatient,facility,10,UN,6.99,6.99,0.56,618.77,,4.08,,,percent of total billed charges,,,1.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.99,,,percent of total billed charges,,,6.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.29,,,percent of total billed charges,,,,,,,,,6.99,,,percent of total billed charges,,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.37,,,percent of total billed charges,,,,,,,,,,,,,,,3.77,,,percent of total billed charges,,,3.77,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,3.62,,,percent of total billed charges,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.59,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,6.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,6.99,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,,,,,,,6.99,,,fee schedule,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,5.24,,,percent of total billed charges,,,6.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.99,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.91,,,percent of total billed charges,,
MINOXIDIL 10 MG TAB,2500013900,CDM,637,RC,6808420501,NDC,999,EAPG,,,,outpatient,facility,10,UN,6.99,6.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIRTAZAPINE 15 MG TAB,2500013910,CDM,637,RC,904651961,NDC,,,,,,inpatient,facility,15,UN,0.52,0.52,0.04,0.52,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,0.52,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,
MIRTAZAPINE 15 MG TAB,2500013910,CDM,637,RC,904651961,NDC,,,,,,outpatient,facility,15,UN,0.52,0.52,0.04,618.77,,0.3,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.52,,,percent of total billed charges,,,0.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.47,,,percent of total billed charges,,,,,,,,,0.52,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.19,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,0.52,,,fee schedule,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.37,,,percent of total billed charges,,
MIRTAZAPINE 15 MG TAB,2500013910,CDM,637,RC,904651961,NDC,999,EAPG,,,,outpatient,facility,15,UN,0.52,0.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MISOPROSTOL 100 MCG TAB,2500013930,CDM,637,RC,5976250071,NDC,,,,,,inpatient,facility,100,UN,2.18,2.18,0.17,2.18,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,
MISOPROSTOL 100 MCG TAB,2500013930,CDM,637,RC,5976250071,NDC,,,,,,outpatient,facility,100,UN,2.18,2.18,0.17,618.77,,1.27,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.18,,,percent of total billed charges,,,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.96,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.81,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,2.18,,,fee schedule,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,2.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.53,,,percent of total billed charges,,
MISOPROSTOL 100 MCG TAB,2500013930,CDM,637,RC,5976250071,NDC,999,EAPG,,,,outpatient,facility,100,UN,2.18,2.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MISOPROSTOL 200 MCG TAB,2500013932,CDM,637,RC,4338616101,NDC,,,,,,inpatient,facility,200,UN,4.72,4.72,0.38,4.72,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.25,,,percent of total billed charges,,,,,,,,,4.72,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,
MISOPROSTOL 200 MCG TAB,2500013932,CDM,637,RC,4338616101,NDC,,,,,,outpatient,facility,200,UN,4.72,4.72,0.38,618.77,,2.76,,,percent of total billed charges,,,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.72,,,percent of total billed charges,,,4.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.25,,,percent of total billed charges,,,,,,,,,4.72,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.62,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.59,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,4.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.38,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,4.72,,,fee schedule,,,4.39,,,percent of total billed charges,,,,,,,,,,,,,,,4.39,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,4.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.31,,,percent of total billed charges,,
MISOPROSTOL 200 MCG TAB,2500013932,CDM,637,RC,4338616101,NDC,999,EAPG,,,,outpatient,facility,200,UN,4.72,4.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MONTELUKAST  SOD 10 MG TAB,2500014012,CDM,637,RC,1366808105,NDC,,,,,,inpatient,facility,10,UN,16.6,16.6,1.33,16.6,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.94,,,percent of total billed charges,,,,,,,,,16.6,,,percent of total billed charges,,,9.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,8.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.66,,,percent of total billed charges,,
MONTELUKAST  SOD 10 MG TAB,2500014012,CDM,637,RC,1366808105,NDC,,,,,,outpatient,facility,10,UN,16.6,16.6,1.33,618.77,,9.69,,,percent of total billed charges,,,3.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.6,,,percent of total billed charges,,,14.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,14.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,14.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,14.94,,,percent of total billed charges,,,,,,,,,16.6,,,percent of total billed charges,,,11.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,8.96,,,percent of total billed charges,,,8.96,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.66,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.62,,,percent of total billed charges,,,6.29,,,percent of total billed charges,,,8.6,,,percent of total billed charges,,,,,,,,,,,,,,,3.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,16.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.33,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,16.6,,,fee schedule,,,15.44,,,percent of total billed charges,,,,,,,,,,,,,,,15.44,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,12.45,,,percent of total billed charges,,,16.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.6,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.66,,,percent of total billed charges,,
MONTELUKAST  SOD 10 MG TAB,2500014012,CDM,637,RC,1366808105,NDC,999,EAPG,,,,outpatient,facility,10,UN,16.6,16.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF 15 MG TAB,2500014044,CDM,637,RC,54023524,NDC,,,,,,inpatient,facility,15,UN,3,3,0.24,3,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,,,,,,,3,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,
MORPHINE SULF 15 MG TAB,2500014044,CDM,637,RC,54023524,NDC,,,,,,outpatient,facility,15,UN,3,3,0.24,618.77,,1.75,,,percent of total billed charges,,,0.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3,,,percent of total billed charges,,,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.7,,,percent of total billed charges,,,,,,,,,3,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.11,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,3,,,fee schedule,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,2.79,,,percent of total billed charges,,,2.79,,,percent of total billed charges,,,2.79,,,percent of total billed charges,,,2.25,,,percent of total billed charges,,,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.11,,,percent of total billed charges,,
MORPHINE SULF 15 MG TAB,2500014044,CDM,637,RC,54023524,NDC,999,EAPG,,,,outpatient,facility,15,UN,3,3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE ORAL 10 MG/0.5 ML UDC,2500014055,CDM,637,RC,6809404558,NDC,,,,,,inpatient,facility,0.5,UN,11.72,11.72,0.94,11.72,,,,,,,,,,,,,,11.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.55,,,percent of total billed charges,,,,,,,,,11.72,,,percent of total billed charges,,,6.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.72,,,percent of total billed charges,,,,,,,,,,,,,,,11.72,,,percent of total billed charges,,,6.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,11.72,,,percent of total billed charges,,,11.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.23,,,percent of total billed charges,,
MORPHINE ORAL 10 MG/0.5 ML UDC,2500014055,CDM,637,RC,6809404558,NDC,,,,,,outpatient,facility,0.5,UN,11.72,11.72,0.94,618.77,,6.84,,,percent of total billed charges,,,2.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.72,,,percent of total billed charges,,,10.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,10.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,10.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.55,,,percent of total billed charges,,,,,,,,,11.72,,,percent of total billed charges,,,7.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9,,,percent of total billed charges,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,11.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.11,,,percent of total billed charges,,,11.72,,,percent of total billed charges,,,11.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,4.44,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.34,,,percent of total billed charges,,,4.34,,,percent of total billed charges,,,11.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.94,,,percent of total billed charges,,,11.72,,,percent of total billed charges,,,11.72,,,percent of total billed charges,,,,,,,,,,,,,,,11.72,,,percent of total billed charges,,,11.72,,,percent of total billed charges,,,,,,,,,11.72,,,fee schedule,,,10.9,,,percent of total billed charges,,,,,,,,,,,,,,,10.9,,,percent of total billed charges,,,10.9,,,percent of total billed charges,,,10.9,,,percent of total billed charges,,,8.79,,,percent of total billed charges,,,11.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.72,,,percent of total billed charges,,,11.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.86,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.23,,,percent of total billed charges,,
MORPHINE ORAL 10 MG/0.5 ML UDC,2500014055,CDM,637,RC,6809404558,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,11.72,11.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF SR 15 MG TAB,2500014061,CDM,637,RC,904655761,NDC,,,,,,inpatient,facility,15,UN,3.76,3.76,0.3,3.76,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,
MORPHINE SULF SR 15 MG TAB,2500014061,CDM,637,RC,904655761,NDC,,,,,,outpatient,facility,15,UN,3.76,3.76,0.3,618.77,,2.2,,,percent of total billed charges,,,0.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.76,,,percent of total billed charges,,,3.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.38,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,3.76,,,fee schedule,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,2.82,,,percent of total billed charges,,,3.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.64,,,percent of total billed charges,,
MORPHINE SULF SR 15 MG TAB,2500014061,CDM,637,RC,904655761,NDC,999,EAPG,,,,outpatient,facility,15,UN,3.76,3.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF SR 30 MG TAB,2500014062,CDM,637,RC,904655861,NDC,,,,,,inpatient,facility,30,UN,4.13,4.13,0.33,4.13,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.72,,,percent of total billed charges,,,,,,,,,4.13,,,percent of total billed charges,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,
MORPHINE SULF SR 30 MG TAB,2500014062,CDM,637,RC,904655861,NDC,,,,,,outpatient,facility,30,UN,4.13,4.13,0.33,618.77,,2.41,,,percent of total billed charges,,,0.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.13,,,percent of total billed charges,,,3.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.72,,,percent of total billed charges,,,,,,,,,4.13,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.53,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,4.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.33,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,,,,,,,4.13,,,fee schedule,,,3.84,,,percent of total billed charges,,,,,,,,,,,,,,,3.84,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,4.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.13,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.9,,,percent of total billed charges,,
MORPHINE SULF SR 30 MG TAB,2500014062,CDM,637,RC,904655861,NDC,999,EAPG,,,,outpatient,facility,30,UN,4.13,4.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MULTIVITAMINS INJ ADULT 10 ML,2500014079,CDM,250,RC,5464356491,NDC,,,,,,inpatient,facility,10,UN,50.75,50.75,4.06,50.75,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.68,,,percent of total billed charges,,,,,,,,,50.75,,,percent of total billed charges,,,28.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,26.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,
MULTIVITAMINS INJ ADULT 10 ML,2500014079,CDM,250,RC,5464356491,NDC,,,,,,outpatient,facility,10,UN,50.75,50.75,4.06,618.77,,29.64,,,percent of total billed charges,,,9.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,50.75,,,percent of total billed charges,,,44.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,44.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,44.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,18.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,45.68,,,percent of total billed charges,,,,,,,,,50.75,,,percent of total billed charges,,,34.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.46,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.57,,,percent of total billed charges,,,19.22,,,percent of total billed charges,,,26.28,,,percent of total billed charges,,,,,,,,,,,,,,,10.15,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,20.3,,,percent of total billed charges,,,20.3,,,percent of total billed charges,,,50.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,50.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.06,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,,,,,,,50.75,,,fee schedule,,,20.3,,,percent of total billed charges,,,,,,,,,,,,,,,20.3,,,percent of total billed charges,,,20.3,,,percent of total billed charges,,,20.3,,,percent of total billed charges,,,38.06,,,percent of total billed charges,,,50.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,50.75,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.64,,,percent of total billed charges,,
MULTIVITAMINS INJ ADULT 10 ML,2500014079,CDM,250,RC,5464356491,NDC,999,EAPG,,,,outpatient,facility,10,UN,50.75,50.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MULTIVITAMIN TAB,2500014094,CDM,637,RC,904053961,NDC,,,,,,inpatient,facility,1,UN,1.55,1.55,0.12,1.55,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,
MULTIVITAMIN TAB,2500014094,CDM,637,RC,904053961,NDC,,,,,,outpatient,facility,1,UN,1.55,1.55,0.12,618.77,,0.91,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.55,,,percent of total billed charges,,,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.4,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.57,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,1.55,,,fee schedule,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.09,,,percent of total billed charges,,
MULTIVITAMIN TAB,2500014094,CDM,637,RC,904053961,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.55,1.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MULTIVITAMIN/MINERALS TAB,2500014098,CDM,637,RC,904549261,NDC,,,,,,inpatient,facility,1,UN,0.31,0.31,0.02,0.31,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,0.31,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,
MULTIVITAMIN/MINERALS TAB,2500014098,CDM,637,RC,904549261,NDC,,,,,,outpatient,facility,1,UN,0.31,0.31,0.02,618.77,,0.18,,,percent of total billed charges,,,0.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.31,,,percent of total billed charges,,,0.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.28,,,percent of total billed charges,,,,,,,,,0.31,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.11,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,0.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,0.31,,,fee schedule,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.22,,,percent of total billed charges,,
MULTIVITAMIN/MINERALS TAB,2500014098,CDM,637,RC,904549261,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.31,0.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MUPIROCIN 2  OINT 22 GM,2500014122,CDM,637,RC,5167213120,NDC,,,,,,inpatient,facility,22,UN,82.5,82.5,6.6,82.5,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.25,,,percent of total billed charges,,,,,,,,,82.5,,,percent of total billed charges,,,45.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,43.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.93,,,percent of total billed charges,,
MUPIROCIN 2  OINT 22 GM,2500014122,CDM,637,RC,5167213120,NDC,,,,,,outpatient,facility,22,UN,82.5,82.5,6.6,618.77,,48.18,,,percent of total billed charges,,,16.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,82.5,,,percent of total billed charges,,,72.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,72.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,72.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,30.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,74.25,,,percent of total billed charges,,,,,,,,,82.5,,,percent of total billed charges,,,55.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.36,,,percent of total billed charges,,,,,,,,,,,,,,,44.55,,,percent of total billed charges,,,44.55,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.02,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.7,,,percent of total billed charges,,,31.25,,,percent of total billed charges,,,42.73,,,percent of total billed charges,,,,,,,,,,,,,,,16.5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,30.52,,,percent of total billed charges,,,30.52,,,percent of total billed charges,,,82.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,82.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.6,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,82.5,,,fee schedule,,,76.74,,,percent of total billed charges,,,,,,,,,,,,,,,76.74,,,percent of total billed charges,,,76.74,,,percent of total billed charges,,,76.74,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,82.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,57.93,,,percent of total billed charges,,
MUPIROCIN 2  OINT 22 GM,2500014122,CDM,637,RC,5167213120,NDC,999,EAPG,,,,outpatient,facility,22,UN,82.5,82.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MUPIROCIN NASAL 2  1 GM,2500014125,CDM,637,RC,4580211222,NDC,,,,,,inpatient,facility,1,UN,1.35,1.35,0.11,1.35,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,
MUPIROCIN NASAL 2  1 GM,2500014125,CDM,637,RC,4580211222,NDC,,,,,,outpatient,facility,1,UN,1.35,1.35,0.11,618.77,,0.79,,,percent of total billed charges,,,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.35,,,percent of total billed charges,,,1.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.22,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,1.35,,,fee schedule,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.95,,,percent of total billed charges,,
MUPIROCIN NASAL 2  1 GM,2500014125,CDM,637,RC,4580211222,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.35,1.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MYCOPHENOLATE 250 MG CAP,2500014150,CDM,636,RC,J7517,HCPCS,1672909401,NDC,,,,inpatient,facility,250,UN,12.93,12.93,1.03,12.93,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.64,,,percent of total billed charges,,,,,,,,,12.93,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,6.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.08,,,percent of total billed charges,,
MYCOPHENOLATE 250 MG CAP,2500014150,CDM,636,RC,J7517,HCPCS,1672909401,NDC,,,,outpatient,facility,250,UN,12.93,12.93,0.17,618.77,,7.55,,,percent of total billed charges,,,2.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,12.93,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.64,,,percent of total billed charges,,,,,,,,,12.93,,,percent of total billed charges,,,8.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.74,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.83,,,percent of total billed charges,,,4.9,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,12.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.03,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,,,,,,,12.93,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.17,,,fee schedule,,,12.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,12.93,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.08,,,percent of total billed charges,,
MYCOPHENOLATE 250 MG CAP,2500014150,CDM,636,RC,J7517,HCPCS,1672909401,NDC,496,EAPG,,outpatient,facility,250,UN,12.93,12.93,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MYCOPHENOLATE 180 MG TAB,2500014152,CDM,637,RC,J7518,HCPCS,904678504,NDC,,,,inpatient,facility,180,UN,13.7,13.7,1.1,13.7,,,,,,,,,,,,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.33,,,percent of total billed charges,,,,,,,,,13.7,,,percent of total billed charges,,,7.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,13.7,,,percent of total billed charges,,,7.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.62,,,percent of total billed charges,,
MYCOPHENOLATE 180 MG TAB,2500014152,CDM,637,RC,J7518,HCPCS,904678504,NDC,,,,outpatient,facility,180,UN,13.7,13.7,0.39,618.77,,8,,,percent of total billed charges,,,2.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.33,,,percent of total billed charges,,,,,,,,,13.7,,,percent of total billed charges,,,9.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.14,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.41,,,percent of total billed charges,,,5.19,,,percent of total billed charges,,,7.1,,,percent of total billed charges,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,13.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,13.7,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,,,,,,,13.7,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.39,,,fee schedule,,,13.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.7,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.62,,,percent of total billed charges,,
MYCOPHENOLATE 180 MG TAB,2500014152,CDM,637,RC,J7518,HCPCS,904678504,NDC,496,EAPG,,outpatient,facility,180,UN,13.7,13.7,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NALTREXONE HCL 50 MG TAB,2500014200,CDM,637,RC,4733532683,NDC,,,,,,inpatient,facility,50,UN,14.12,14.12,1.13,14.12,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.71,,,percent of total billed charges,,,,,,,,,14.12,,,percent of total billed charges,,,7.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.92,,,percent of total billed charges,,
NALTREXONE HCL 50 MG TAB,2500014200,CDM,637,RC,4733532683,NDC,,,,,,outpatient,facility,50,UN,14.12,14.12,1.13,618.77,,8.25,,,percent of total billed charges,,,2.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.12,,,percent of total billed charges,,,12.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.71,,,percent of total billed charges,,,,,,,,,14.12,,,percent of total billed charges,,,9.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.84,,,percent of total billed charges,,,,,,,,,,,,,,,7.62,,,percent of total billed charges,,,7.62,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,5.35,,,percent of total billed charges,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.82,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.22,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,14.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.13,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,,,,,,,14.12,,,fee schedule,,,13.13,,,percent of total billed charges,,,,,,,,,,,,,,,13.13,,,percent of total billed charges,,,13.13,,,percent of total billed charges,,,13.13,,,percent of total billed charges,,,10.59,,,percent of total billed charges,,,14.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.12,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.92,,,percent of total billed charges,,
NALTREXONE HCL 50 MG TAB,2500014200,CDM,637,RC,4733532683,NDC,999,EAPG,,,,outpatient,facility,50,UN,14.12,14.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAPROXEN 250 MG TAB,2500014240,CDM,637,RC,5026859415,NDC,,,,,,inpatient,facility,250,UN,2.57,2.57,0.21,2.57,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,
NAPROXEN 250 MG TAB,2500014240,CDM,637,RC,5026859415,NDC,,,,,,outpatient,facility,250,UN,2.57,2.57,0.21,618.77,,1.5,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.57,,,percent of total billed charges,,,2.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.31,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,2.57,,,fee schedule,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,2.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.8,,,percent of total billed charges,,
NAPROXEN 250 MG TAB,2500014240,CDM,637,RC,5026859415,NDC,999,EAPG,,,,outpatient,facility,250,UN,2.57,2.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAPROXEN 375 MG TAB,2500014241,CDM,637,RC,6846218905,NDC,,,,,,inpatient,facility,375,UN,3.23,3.23,0.26,3.23,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.27,,,percent of total billed charges,,
NAPROXEN 375 MG TAB,2500014241,CDM,637,RC,6846218905,NDC,,,,,,outpatient,facility,375,UN,3.23,3.23,0.26,618.77,,1.89,,,percent of total billed charges,,,0.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.23,,,percent of total billed charges,,,2.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.91,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,3.23,,,fee schedule,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,3.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.27,,,percent of total billed charges,,
NAPROXEN 375 MG TAB,2500014241,CDM,637,RC,6846218905,NDC,999,EAPG,,,,outpatient,facility,375,UN,3.23,3.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOMYCIN/POLY/BACI OINT 0.9 GM,2500014294,CDM,637,RC,4580214370,NDC,,,,,,inpatient,facility,0.9,UN,0.5,0.5,0.04,0.5,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,
NEOMYCIN/POLY/BACI OINT 0.9 GM,2500014294,CDM,637,RC,4580214370,NDC,,,,,,outpatient,facility,0.9,UN,0.5,0.5,0.04,618.77,,0.29,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.5,,,percent of total billed charges,,,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.45,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.18,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,0.5,,,fee schedule,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,0.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.35,,,percent of total billed charges,,
NEOMYCIN/POLY/BACI OINT 0.9 GM,2500014294,CDM,637,RC,4580214370,NDC,999,EAPG,,,,outpatient,facility,0.9,UN,0.5,0.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOMYCIN/POLY/BACI OINT 15 GM,2500014295,CDM,637,RC,472017934,NDC,,,,,,inpatient,facility,14,UN,17.79,17.79,1.42,17.79,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.01,,,percent of total billed charges,,,,,,,,,17.79,,,percent of total billed charges,,,9.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,,9.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,
NEOMYCIN/POLY/BACI OINT 15 GM,2500014295,CDM,637,RC,472017934,NDC,,,,,,outpatient,facility,14,UN,17.79,17.79,1.42,618.77,,10.39,,,percent of total billed charges,,,3.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,17.79,,,percent of total billed charges,,,15.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,15.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,15.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,16.01,,,percent of total billed charges,,,,,,,,,17.79,,,percent of total billed charges,,,12.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,9.61,,,percent of total billed charges,,,9.61,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.28,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.52,,,percent of total billed charges,,,6.74,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.58,,,percent of total billed charges,,,6.58,,,percent of total billed charges,,,17.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.42,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,,,,,,,17.79,,,fee schedule,,,16.55,,,percent of total billed charges,,,,,,,,,,,,,,,16.55,,,percent of total billed charges,,,16.55,,,percent of total billed charges,,,16.55,,,percent of total billed charges,,,13.34,,,percent of total billed charges,,,17.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,17.79,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,12.49,,,percent of total billed charges,,
NEOMYCIN/POLY/BACI OINT 15 GM,2500014295,CDM,637,RC,472017934,NDC,999,EAPG,,,,outpatient,facility,14,UN,17.79,17.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOMYCIN/POLY/HC OP SUSP 7.5ML,2500014302,CDM,637,RC,6131464175,NDC,,,,,,inpatient,facility,7.5,UN,561.83,561.83,44.95,561.83,,,,,,,,,,,,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,505.65,,,percent of total billed charges,,,,,,,,,561.83,,,percent of total billed charges,,,311.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,561.83,,,percent of total billed charges,,,292.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.95,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,394.52,,,percent of total billed charges,,
NEOMYCIN/POLY/HC OP SUSP 7.5ML,2500014302,CDM,637,RC,6131464175,NDC,,,,,,outpatient,facility,7.5,UN,561.83,561.83,44.95,618.77,,328.11,,,percent of total billed charges,,,109.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,561.83,,,percent of total billed charges,,,494.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,494.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,494.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,205.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,505.65,,,percent of total billed charges,,,,,,,,,561.83,,,percent of total billed charges,,,380.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.49,,,percent of total billed charges,,,,,,,,,,,,,,,303.39,,,percent of total billed charges,,,303.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,292.94,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,426.99,,,percent of total billed charges,,,212.82,,,percent of total billed charges,,,290.97,,,percent of total billed charges,,,,,,,,,,,,,,,112.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,207.88,,,percent of total billed charges,,,207.88,,,percent of total billed charges,,,561.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,561.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,44.95,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,561.83,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,,,,,,,561.83,,,fee schedule,,,522.61,,,percent of total billed charges,,,,,,,,,,,,,,,522.61,,,percent of total billed charges,,,522.61,,,percent of total billed charges,,,522.61,,,percent of total billed charges,,,421.37,,,percent of total billed charges,,,561.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,561.83,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,394.52,,,percent of total billed charges,,
NEOMYCIN/POLY/HC OP SUSP 7.5ML,2500014302,CDM,637,RC,6131464175,NDC,999,EAPG,,,,outpatient,facility,7.5,UN,561.83,561.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOMYCIN/POLY/HC OTIC SUS 10ML,2500014304,CDM,637,RC,2420863562,NDC,,,,,,inpatient,facility,10,UN,276.87,276.87,22.15,276.87,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.18,,,percent of total billed charges,,,,,,,,,276.87,,,percent of total billed charges,,,153.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,144.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.15,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.42,,,percent of total billed charges,,
NEOMYCIN/POLY/HC OTIC SUS 10ML,2500014304,CDM,637,RC,2420863562,NDC,,,,,,outpatient,facility,10,UN,276.87,276.87,22.15,618.77,,161.69,,,percent of total billed charges,,,53.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,276.87,,,percent of total billed charges,,,243.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,243.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,243.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,101.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,249.18,,,percent of total billed charges,,,,,,,,,276.87,,,percent of total billed charges,,,187.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,212.64,,,percent of total billed charges,,,,,,,,,,,,,,,149.51,,,percent of total billed charges,,,149.51,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,144.36,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210.42,,,percent of total billed charges,,,104.88,,,percent of total billed charges,,,143.39,,,percent of total billed charges,,,,,,,,,,,,,,,55.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,102.44,,,percent of total billed charges,,,102.44,,,percent of total billed charges,,,276.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,276.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.15,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,276.87,,,fee schedule,,,257.54,,,percent of total billed charges,,,,,,,,,,,,,,,257.54,,,percent of total billed charges,,,257.54,,,percent of total billed charges,,,257.54,,,percent of total billed charges,,,207.65,,,percent of total billed charges,,,276.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,194.42,,,percent of total billed charges,,
NEOMYCIN/POLY/HC OTIC SUS 10ML,2500014304,CDM,637,RC,2420863562,NDC,999,EAPG,,,,outpatient,facility,10,UN,276.87,276.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOMYCIN/POLY/HC OTIC SOL 10ML,2500014306,CDM,637,RC,2420863562,NDC,,,,,,inpatient,facility,10,UN,276.87,276.87,22.15,276.87,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.18,,,percent of total billed charges,,,,,,,,,276.87,,,percent of total billed charges,,,153.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,144.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.15,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.42,,,percent of total billed charges,,
NEOMYCIN/POLY/HC OTIC SOL 10ML,2500014306,CDM,637,RC,2420863562,NDC,,,,,,outpatient,facility,10,UN,276.87,276.87,22.15,618.77,,161.69,,,percent of total billed charges,,,53.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,276.87,,,percent of total billed charges,,,243.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,243.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,243.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,101.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,249.18,,,percent of total billed charges,,,,,,,,,276.87,,,percent of total billed charges,,,187.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,212.64,,,percent of total billed charges,,,,,,,,,,,,,,,149.51,,,percent of total billed charges,,,149.51,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,144.36,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210.42,,,percent of total billed charges,,,104.88,,,percent of total billed charges,,,143.39,,,percent of total billed charges,,,,,,,,,,,,,,,55.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,102.44,,,percent of total billed charges,,,102.44,,,percent of total billed charges,,,276.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,276.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.15,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,276.87,,,fee schedule,,,257.54,,,percent of total billed charges,,,,,,,,,,,,,,,257.54,,,percent of total billed charges,,,257.54,,,percent of total billed charges,,,257.54,,,percent of total billed charges,,,207.65,,,percent of total billed charges,,,276.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,194.42,,,percent of total billed charges,,
NEOMYCIN/POLY/HC OTIC SOL 10ML,2500014306,CDM,637,RC,2420863562,NDC,999,EAPG,,,,outpatient,facility,10,UN,276.87,276.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOMYCIN/POLY/DEX OP ONT 3.5GM,2500014321,CDM,637,RC,2420879535,NDC,,,,,,inpatient,facility,3.5,UN,65.54,65.54,5.24,65.54,,,,,,,,,,,,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.99,,,percent of total billed charges,,,,,,,,,65.54,,,percent of total billed charges,,,36.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,65.54,,,percent of total billed charges,,,34.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.24,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.02,,,percent of total billed charges,,
NEOMYCIN/POLY/DEX OP ONT 3.5GM,2500014321,CDM,637,RC,2420879535,NDC,,,,,,outpatient,facility,3.5,UN,65.54,65.54,5.24,618.77,,38.28,,,percent of total billed charges,,,12.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,65.54,,,percent of total billed charges,,,57.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,57.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,57.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,23.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,58.99,,,percent of total billed charges,,,,,,,,,65.54,,,percent of total billed charges,,,44.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.33,,,percent of total billed charges,,,,,,,,,,,,,,,35.39,,,percent of total billed charges,,,35.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.17,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.81,,,percent of total billed charges,,,24.83,,,percent of total billed charges,,,33.94,,,percent of total billed charges,,,,,,,,,,,,,,,13.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,24.25,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,65.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,65.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.24,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,65.54,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,,,,,,,65.54,,,fee schedule,,,60.97,,,percent of total billed charges,,,,,,,,,,,,,,,60.97,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,49.16,,,percent of total billed charges,,,65.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,65.54,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,46.02,,,percent of total billed charges,,
NEOMYCIN/POLY/DEX OP ONT 3.5GM,2500014321,CDM,637,RC,2420879535,NDC,999,EAPG,,,,outpatient,facility,3.5,UN,65.54,65.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIACIN SR 250 MG CAP,2500014385,CDM,637,RC,1000670020,NDC,,,,,,inpatient,facility,250,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
NIACIN SR 250 MG CAP,2500014385,CDM,637,RC,1000670020,NDC,,,,,,outpatient,facility,250,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
NIACIN SR 250 MG CAP,2500014385,CDM,637,RC,1000670020,NDC,999,EAPG,,,,outpatient,facility,250,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICARDIPINE HCL 25 MG/10ML AMP,2500014402,CDM,250,RC,517073510,NDC,,,,,,inpatient,facility,10,UN,101.44,101.44,8.12,101.44,,,,,,,,,,,,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.3,,,percent of total billed charges,,,,,,,,,101.44,,,percent of total billed charges,,,56.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,101.44,,,percent of total billed charges,,,52.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.12,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.23,,,percent of total billed charges,,
NICARDIPINE HCL 25 MG/10ML AMP,2500014402,CDM,250,RC,517073510,NDC,,,,,,outpatient,facility,10,UN,101.44,101.44,8.12,618.77,,59.24,,,percent of total billed charges,,,19.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,101.44,,,percent of total billed charges,,,89.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,89.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,89.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,37.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,91.3,,,percent of total billed charges,,,,,,,,,101.44,,,percent of total billed charges,,,68.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.89,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.09,,,percent of total billed charges,,,38.43,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,40.58,,,percent of total billed charges,,,40.58,,,percent of total billed charges,,,101.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,101.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.12,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,101.44,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,,,,,,,101.44,,,fee schedule,,,40.58,,,percent of total billed charges,,,,,,,,,,,,,,,40.58,,,percent of total billed charges,,,40.58,,,percent of total billed charges,,,40.58,,,percent of total billed charges,,,76.08,,,percent of total billed charges,,,101.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,101.44,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,71.23,,,percent of total billed charges,,
NICARDIPINE HCL 25 MG/10ML AMP,2500014402,CDM,250,RC,517073510,NDC,999,EAPG,,,,outpatient,facility,10,UN,101.44,101.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICOTINE 14 MG/24 HR PATCH,2500014410,CDM,637,RC,536589588,NDC,,,,,,inpatient,facility,1,UN,2.57,2.57,0.21,2.57,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,
NICOTINE 14 MG/24 HR PATCH,2500014410,CDM,637,RC,536589588,NDC,,,,,,outpatient,facility,1,UN,2.57,2.57,0.21,618.77,,1.5,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.57,,,percent of total billed charges,,,2.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.31,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,2.57,,,fee schedule,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,2.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.8,,,percent of total billed charges,,
NICOTINE 14 MG/24 HR PATCH,2500014410,CDM,637,RC,536589588,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.57,2.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICOTINE 21MG/ 24 HR PATCH,2500014411,CDM,637,RC,536589688,NDC,,,,,,inpatient,facility,1,UN,2.57,2.57,0.21,2.57,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,
NICOTINE 21MG/ 24 HR PATCH,2500014411,CDM,637,RC,536589688,NDC,,,,,,outpatient,facility,1,UN,2.57,2.57,0.21,618.77,,1.5,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.57,,,percent of total billed charges,,,2.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.31,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,2.57,,,fee schedule,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,2.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.8,,,percent of total billed charges,,
NICOTINE 21MG/ 24 HR PATCH,2500014411,CDM,637,RC,536589688,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.57,2.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICOTINE 7 MG /24HR PATCH,2500014412,CDM,637,RC,536589488,NDC,,,,,,inpatient,facility,1,UN,2.57,2.57,0.21,2.57,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,
NICOTINE 7 MG /24HR PATCH,2500014412,CDM,637,RC,536589488,NDC,,,,,,outpatient,facility,1,UN,2.57,2.57,0.21,618.77,,1.5,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.57,,,percent of total billed charges,,,2.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.31,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,2.57,,,fee schedule,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,2.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.8,,,percent of total billed charges,,
NICOTINE 7 MG /24HR PATCH,2500014412,CDM,637,RC,536589488,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.57,2.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICOTINE POLACRILEX 2 MG GUM,2500014415,CDM,637,RC,536311201,NDC,,,,,,inpatient,facility,2,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
NICOTINE POLACRILEX 2 MG GUM,2500014415,CDM,637,RC,536311201,NDC,,,,,,outpatient,facility,2,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
NICOTINE POLACRILEX 2 MG GUM,2500014415,CDM,637,RC,536311201,NDC,999,EAPG,,,,outpatient,facility,2,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICOTINE POLACRILEX 4 MG GUM,2500014416,CDM,637,RC,536303023,NDC,,,,,,inpatient,facility,4,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
NICOTINE POLACRILEX 4 MG GUM,2500014416,CDM,637,RC,536303023,NDC,,,,,,outpatient,facility,4,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
NICOTINE POLACRILEX 4 MG GUM,2500014416,CDM,637,RC,536303023,NDC,999,EAPG,,,,outpatient,facility,4,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICOTINE POLACRILEX 4 MG LOZ.,2500014417,CDM,637,RC,536124181,NDC,,,,,,inpatient,facility,4,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
NICOTINE POLACRILEX 4 MG LOZ.,2500014417,CDM,637,RC,536124181,NDC,,,,,,outpatient,facility,4,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
NICOTINE POLACRILEX 4 MG LOZ.,2500014417,CDM,637,RC,536124181,NDC,999,EAPG,,,,outpatient,facility,4,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICOTINE POLACRILEX 2 MG LOZ.,2500014418,CDM,637,RC,4580234405,NDC,,,,,,inpatient,facility,2,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
NICOTINE POLACRILEX 2 MG LOZ.,2500014418,CDM,637,RC,4580234405,NDC,,,,,,outpatient,facility,2,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
NICOTINE POLACRILEX 2 MG LOZ.,2500014418,CDM,637,RC,4580234405,NDC,999,EAPG,,,,outpatient,facility,2,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIFEDIPINE 10 MG CAP,2500014420,CDM,637,RC,2315519401,NDC,,,,,,inpatient,facility,10,UN,3.53,3.53,0.28,3.53,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.18,,,percent of total billed charges,,,,,,,,,3.53,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,
NIFEDIPINE 10 MG CAP,2500014420,CDM,637,RC,2315519401,NDC,,,,,,outpatient,facility,10,UN,3.53,3.53,0.28,618.77,,2.06,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.53,,,percent of total billed charges,,,3.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.18,,,percent of total billed charges,,,,,,,,,3.53,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.31,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,3.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,3.53,,,fee schedule,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,3.28,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,3.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.48,,,percent of total billed charges,,
NIFEDIPINE 10 MG CAP,2500014420,CDM,637,RC,2315519401,NDC,999,EAPG,,,,outpatient,facility,10,UN,3.53,3.53,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIFEDIPINE 30 MG TABCR,2500014423,CDM,637,RC,5074262001,NDC,,,,,,inpatient,facility,30,UN,4.58,4.58,0.37,4.58,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,4.58,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,
NIFEDIPINE 30 MG TABCR,2500014423,CDM,637,RC,5074262001,NDC,,,,,,outpatient,facility,30,UN,4.58,4.58,0.37,618.77,,2.67,,,percent of total billed charges,,,0.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.58,,,percent of total billed charges,,,4.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.12,,,percent of total billed charges,,,,,,,,,4.58,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.69,,,percent of total billed charges,,,1.69,,,percent of total billed charges,,,4.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,,,,,,,4.58,,,fee schedule,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,3.44,,,percent of total billed charges,,,4.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.58,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.22,,,percent of total billed charges,,
NIFEDIPINE 30 MG TABCR,2500014423,CDM,637,RC,5074262001,NDC,999,EAPG,,,,outpatient,facility,30,UN,4.58,4.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIFEDIPINE 60 MG TABCR,2500014424,CDM,637,RC,5074226101,NDC,,,,,,inpatient,facility,60,UN,7.56,7.56,0.6,7.56,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,7.56,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,3.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,
NIFEDIPINE 60 MG TABCR,2500014424,CDM,637,RC,5074226101,NDC,,,,,,outpatient,facility,60,UN,7.56,7.56,0.6,618.77,,4.42,,,percent of total billed charges,,,1.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.56,,,percent of total billed charges,,,6.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.8,,,percent of total billed charges,,,,,,,,,7.56,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,4.08,,,percent of total billed charges,,,4.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.94,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.75,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.8,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,7.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.6,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,,,,,,,7.56,,,fee schedule,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,7.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.56,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.31,,,percent of total billed charges,,
NIFEDIPINE 60 MG TABCR,2500014424,CDM,637,RC,5074226101,NDC,999,EAPG,,,,outpatient,facility,60,UN,7.56,7.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIFEDIPINE 90 MG TABCR,2500014425,CDM,637,RC,5074226201,NDC,,,,,,inpatient,facility,90,UN,8.45,8.45,0.68,8.45,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.6,,,percent of total billed charges,,,,,,,,,8.45,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,4.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.93,,,percent of total billed charges,,
NIFEDIPINE 90 MG TABCR,2500014425,CDM,637,RC,5074226201,NDC,,,,,,outpatient,facility,90,UN,8.45,8.45,0.68,618.77,,4.93,,,percent of total billed charges,,,1.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.45,,,percent of total billed charges,,,7.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.6,,,percent of total billed charges,,,,,,,,,8.45,,,percent of total billed charges,,,5.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.49,,,percent of total billed charges,,,,,,,,,,,,,,,4.56,,,percent of total billed charges,,,4.56,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.41,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.42,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,8.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.68,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,8.45,,,fee schedule,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,8.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.93,,,percent of total billed charges,,
NIFEDIPINE 90 MG TABCR,2500014425,CDM,637,RC,5074226201,NDC,999,EAPG,,,,outpatient,facility,90,UN,8.45,8.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROFURANTOIN MONO 100 MG CAP,2500014464,CDM,637,RC,4778130301,NDC,,,,,,inpatient,facility,100,UN,12.57,12.57,1.01,12.57,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,,,,,,,12.57,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,6.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.83,,,percent of total billed charges,,
NITROFURANTOIN MONO 100 MG CAP,2500014464,CDM,637,RC,4778130301,NDC,,,,,,outpatient,facility,100,UN,12.57,12.57,1.01,618.77,,7.34,,,percent of total billed charges,,,2.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,12.57,,,percent of total billed charges,,,11.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,11.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,11.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.31,,,percent of total billed charges,,,,,,,,,12.57,,,percent of total billed charges,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.65,,,percent of total billed charges,,,,,,,,,,,,,,,6.79,,,percent of total billed charges,,,6.79,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.55,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.55,,,percent of total billed charges,,,4.76,,,percent of total billed charges,,,6.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.65,,,percent of total billed charges,,,4.65,,,percent of total billed charges,,,12.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.01,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,,,,,,,12.57,,,fee schedule,,,11.69,,,percent of total billed charges,,,,,,,,,,,,,,,11.69,,,percent of total billed charges,,,11.69,,,percent of total billed charges,,,11.69,,,percent of total billed charges,,,9.43,,,percent of total billed charges,,,12.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,12.57,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.83,,,percent of total billed charges,,
NITROFURANTOIN MONO 100 MG CAP,2500014464,CDM,637,RC,4778130301,NDC,999,EAPG,,,,outpatient,facility,100,UN,12.57,12.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 0.1 MG PATCH,2500014470,CDM,637,RC,378910293,NDC,,,,,,inpatient,facility,1,UN,6.14,6.14,0.49,6.14,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.53,,,percent of total billed charges,,,,,,,,,6.14,,,percent of total billed charges,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.31,,,percent of total billed charges,,
NITROGLYCERIN 0.1 MG PATCH,2500014470,CDM,637,RC,378910293,NDC,,,,,,outpatient,facility,1,UN,6.14,6.14,0.49,618.77,,3.59,,,percent of total billed charges,,,1.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.14,,,percent of total billed charges,,,5.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.53,,,percent of total billed charges,,,,,,,,,6.14,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,3.32,,,percent of total billed charges,,,3.32,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,3.18,,,percent of total billed charges,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.27,,,percent of total billed charges,,,2.27,,,percent of total billed charges,,,6.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.49,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,,,,,,,6.14,,,fee schedule,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,5.71,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,6.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.31,,,percent of total billed charges,,
NITROGLYCERIN 0.1 MG PATCH,2500014470,CDM,637,RC,378910293,NDC,999,EAPG,,,,outpatient,facility,1,UN,6.14,6.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 0.2 MG PATCH,2500014472,CDM,637,RC,378910493,NDC,,,,,,inpatient,facility,1,UN,6.27,6.27,0.5,6.27,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,6.27,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,3.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.4,,,percent of total billed charges,,
NITROGLYCERIN 0.2 MG PATCH,2500014472,CDM,637,RC,378910493,NDC,,,,,,outpatient,facility,1,UN,6.27,6.27,0.5,618.77,,3.66,,,percent of total billed charges,,,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.27,,,percent of total billed charges,,,5.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.64,,,percent of total billed charges,,,,,,,,,6.27,,,percent of total billed charges,,,4.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.82,,,percent of total billed charges,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.27,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,3.25,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.32,,,percent of total billed charges,,,2.32,,,percent of total billed charges,,,6.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.5,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,,,,,,,6.27,,,fee schedule,,,5.83,,,percent of total billed charges,,,,,,,,,,,,,,,5.83,,,percent of total billed charges,,,5.83,,,percent of total billed charges,,,5.83,,,percent of total billed charges,,,4.7,,,percent of total billed charges,,,6.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.27,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.4,,,percent of total billed charges,,
NITROGLYCERIN 0.2 MG PATCH,2500014472,CDM,637,RC,378910493,NDC,999,EAPG,,,,outpatient,facility,1,UN,6.27,6.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 0.3 MG SL TAB,2500014473,CDM,637,RC,5976249211,NDC,,,,,,inpatient,facility,0.3,UN,1.25,1.25,0.1,1.25,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,
NITROGLYCERIN 0.3 MG SL TAB,2500014473,CDM,637,RC,5976249211,NDC,,,,,,outpatient,facility,0.3,UN,1.25,1.25,0.1,618.77,,0.73,,,percent of total billed charges,,,0.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.25,,,percent of total billed charges,,,1.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.13,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,1.25,,,fee schedule,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,1.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.88,,,percent of total billed charges,,
NITROGLYCERIN 0.3 MG SL TAB,2500014473,CDM,637,RC,5976249211,NDC,999,EAPG,,,,outpatient,facility,0.3,UN,1.25,1.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 0.3 MG PATCH,2500014474,CDM,637,RC,5074251530,NDC,,,,,,inpatient,facility,1,UN,209.85,209.85,16.79,209.85,,,,,,,,,,,,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.87,,,percent of total billed charges,,,,,,,,,209.85,,,percent of total billed charges,,,116.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,209.85,,,percent of total billed charges,,,109.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.79,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.36,,,percent of total billed charges,,
NITROGLYCERIN 0.3 MG PATCH,2500014474,CDM,637,RC,5074251530,NDC,,,,,,outpatient,facility,1,UN,209.85,209.85,16.79,618.77,,122.55,,,percent of total billed charges,,,40.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,209.85,,,percent of total billed charges,,,184.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,184.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,184.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,76.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,188.87,,,percent of total billed charges,,,,,,,,,209.85,,,percent of total billed charges,,,142.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.16,,,percent of total billed charges,,,,,,,,,,,,,,,113.32,,,percent of total billed charges,,,113.32,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.42,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.49,,,percent of total billed charges,,,79.49,,,percent of total billed charges,,,108.68,,,percent of total billed charges,,,,,,,,,,,,,,,41.97,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,77.64,,,percent of total billed charges,,,77.64,,,percent of total billed charges,,,209.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,209.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.79,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,209.85,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,,,,,,,209.85,,,fee schedule,,,195.2,,,percent of total billed charges,,,,,,,,,,,,,,,195.2,,,percent of total billed charges,,,195.2,,,percent of total billed charges,,,195.2,,,percent of total billed charges,,,157.39,,,percent of total billed charges,,,209.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,209.85,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,147.36,,,percent of total billed charges,,
NITROGLYCERIN 0.3 MG PATCH,2500014474,CDM,637,RC,5074251530,NDC,999,EAPG,,,,outpatient,facility,1,UN,209.85,209.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 0.4 MG SL TAB,2500014475,CDM,637,RC,5976233043,NDC,,,,,,inpatient,facility,0.4,UN,1.25,1.25,0.1,1.25,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,
NITROGLYCERIN 0.4 MG SL TAB,2500014475,CDM,637,RC,5976233043,NDC,,,,,,outpatient,facility,0.4,UN,1.25,1.25,0.1,618.77,,0.73,,,percent of total billed charges,,,0.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.25,,,percent of total billed charges,,,1.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.13,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,1.25,,,fee schedule,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,1.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.88,,,percent of total billed charges,,
NITROGLYCERIN 0.4 MG SL TAB,2500014475,CDM,637,RC,5976233043,NDC,999,EAPG,,,,outpatient,facility,0.4,UN,1.25,1.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 0.4 MG PATCH,2500014476,CDM,637,RC,378911293,NDC,,,,,,inpatient,facility,1,UN,7.16,7.16,0.57,7.16,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.44,,,percent of total billed charges,,,,,,,,,7.16,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,3.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,
NITROGLYCERIN 0.4 MG PATCH,2500014476,CDM,637,RC,378911293,NDC,,,,,,outpatient,facility,1,UN,7.16,7.16,0.57,618.77,,4.18,,,percent of total billed charges,,,1.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.16,,,percent of total billed charges,,,6.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.44,,,percent of total billed charges,,,,,,,,,7.16,,,percent of total billed charges,,,4.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.73,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,2.71,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.65,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,7.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.57,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,7.16,,,fee schedule,,,6.66,,,percent of total billed charges,,,,,,,,,,,,,,,6.66,,,percent of total billed charges,,,6.66,,,percent of total billed charges,,,6.66,,,percent of total billed charges,,,5.37,,,percent of total billed charges,,,7.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.16,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.03,,,percent of total billed charges,,
NITROGLYCERIN 0.4 MG PATCH,2500014476,CDM,637,RC,378911293,NDC,999,EAPG,,,,outpatient,facility,1,UN,7.16,7.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 2  OINT 1 GM PKT,2500014488,CDM,637,RC,281032608,NDC,,,,,,inpatient,facility,1,UN,10,10,0.8,10,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9,,,percent of total billed charges,,,,,,,,,10,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,10,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.02,,,percent of total billed charges,,
NITROGLYCERIN 2  OINT 1 GM PKT,2500014488,CDM,637,RC,281032608,NDC,,,,,,outpatient,facility,1,UN,10,10,0.8,618.77,,5.84,,,percent of total billed charges,,,1.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10,,,percent of total billed charges,,,8.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,8.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,8.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9,,,percent of total billed charges,,,,,,,,,10,,,percent of total billed charges,,,6.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.68,,,percent of total billed charges,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,10,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.6,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.7,,,percent of total billed charges,,,3.7,,,percent of total billed charges,,,10,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.8,,,percent of total billed charges,,,10,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,10,,,fee schedule,,,9.3,,,percent of total billed charges,,,,,,,,,,,,,,,9.3,,,percent of total billed charges,,,9.3,,,percent of total billed charges,,,9.3,,,percent of total billed charges,,,7.5,,,percent of total billed charges,,,10,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.02,,,percent of total billed charges,,
NITROGLYCERIN 2  OINT 1 GM PKT,2500014488,CDM,637,RC,281032608,NDC,999,EAPG,,,,outpatient,facility,1,UN,10,10,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN/D5W 50MG/250ML,2500014497,CDM,250,RC,J3490,HCPCS,338104902,NDC,,,,inpatient,facility,250,UN,74.38,74.38,5.95,74.38,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.94,,,percent of total billed charges,,,,,,,,,74.38,,,percent of total billed charges,,,41.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,38.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.95,,,percent of total billed charges,,,74.38,,,percent of total billed charges,,,74.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.23,,,percent of total billed charges,,
NITROGLYCERIN/D5W 50MG/250ML,2500014497,CDM,250,RC,J3490,HCPCS,338104902,NDC,,,,outpatient,facility,250,UN,74.38,74.38,1.2,618.77,,43.44,,,percent of total billed charges,,,14.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,74.38,,,percent of total billed charges,,,65.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,65.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,65.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,27.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,66.94,,,percent of total billed charges,,,,,,,,,74.38,,,percent of total billed charges,,,50.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.12,,,percent of total billed charges,,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,74.38,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,74.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.78,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.53,,,percent of total billed charges,,,28.18,,,percent of total billed charges,,,38.52,,,percent of total billed charges,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,74.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,74.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.95,,,percent of total billed charges,,,74.38,,,percent of total billed charges,,,74.38,,,percent of total billed charges,,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,74.38,,,percent of total billed charges,,,,,,,,,74.38,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,55.78,,,percent of total billed charges,,,74.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,74.38,,,percent of total billed charges,,,74.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,52.23,,,percent of total billed charges,,
NITROGLYCERIN/D5W 50MG/250ML,2500014497,CDM,250,RC,J3490,HCPCS,338104902,NDC,435,EAPG,,outpatient,facility,250,UN,74.38,74.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROPRUSSIDE SOD 50MG/2ML INJ,2500014500,CDM,250,RC,J3490,HCPCS,1478901202,NDC,,,,inpatient,facility,2,UN,264,264,21.12,264,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,,,,,,,264,,,percent of total billed charges,,,146.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,137.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.12,,,percent of total billed charges,,,264,,,percent of total billed charges,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.38,,,percent of total billed charges,,
NITROPRUSSIDE SOD 50MG/2ML INJ,2500014500,CDM,250,RC,J3490,HCPCS,1478901202,NDC,,,,outpatient,facility,2,UN,264,264,1.2,618.77,,154.18,,,percent of total billed charges,,,51.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,264,,,percent of total billed charges,,,232.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,232.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,232.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,96.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,237.6,,,percent of total billed charges,,,,,,,,,264,,,percent of total billed charges,,,178.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.75,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,264,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.65,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.64,,,percent of total billed charges,,,100,,,percent of total billed charges,,,136.73,,,percent of total billed charges,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,264,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,264,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.12,,,percent of total billed charges,,,264,,,percent of total billed charges,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,264,,,percent of total billed charges,,,,,,,,,264,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,198,,,percent of total billed charges,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,264,,,percent of total billed charges,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,185.38,,,percent of total billed charges,,
NITROPRUSSIDE SOD 50MG/2ML INJ,2500014500,CDM,250,RC,J3490,HCPCS,1478901202,NDC,435,EAPG,,outpatient,facility,2,UN,264,264,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NON-FORMULARY MEDICATION,2500014530,CDM,637,RC,,,,,,,,inpatient,facility,1,UN,0.79,0.79,0.06,0.79,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,
NON-FORMULARY MEDICATION,2500014530,CDM,637,RC,,,,,,,,outpatient,facility,1,UN,0.79,0.79,0.06,618.77,,0.46,,,percent of total billed charges,,,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.71,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,0.79,,,fee schedule,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.55,,,percent of total billed charges,,
NON-FORMULARY MEDICATION,2500014530,CDM,637,RC,999,EAPG,,,,,,outpatient,facility,1,UN,0.79,0.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NOREPINEPHRINE 1MG/ML 4 ML INJ,2500014540,CDM,250,RC,409337504,NDC,,,,,,inpatient,facility,4,UN,74.18,74.18,5.93,74.18,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.76,,,percent of total billed charges,,,,,,,,,74.18,,,percent of total billed charges,,,41.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,38.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.93,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.09,,,percent of total billed charges,,
NOREPINEPHRINE 1MG/ML 4 ML INJ,2500014540,CDM,250,RC,409337504,NDC,,,,,,outpatient,facility,4,UN,74.18,74.18,5.93,618.77,,43.32,,,percent of total billed charges,,,14.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,74.18,,,percent of total billed charges,,,65.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,65.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,65.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,27.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,66.76,,,percent of total billed charges,,,,,,,,,74.18,,,percent of total billed charges,,,50.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.68,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.38,,,percent of total billed charges,,,28.1,,,percent of total billed charges,,,38.42,,,percent of total billed charges,,,,,,,,,,,,,,,14.84,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,29.67,,,percent of total billed charges,,,29.67,,,percent of total billed charges,,,74.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,74.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.93,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,,,,,,,74.18,,,fee schedule,,,29.67,,,percent of total billed charges,,,,,,,,,,,,,,,29.67,,,percent of total billed charges,,,29.67,,,percent of total billed charges,,,29.67,,,percent of total billed charges,,,55.64,,,percent of total billed charges,,,74.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,74.18,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,52.09,,,percent of total billed charges,,
NOREPINEPHRINE 1MG/ML 4 ML INJ,2500014540,CDM,250,RC,409337504,NDC,999,EAPG,,,,outpatient,facility,4,UN,74.18,74.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NOREPINEPHRINE 8 MG NS 250ML,2500014547,CDM,250,RC,,,,,,,,inpatient,facility,250,UN,127.61,127.61,10.21,127.61,,,,,,,,,,,,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.85,,,percent of total billed charges,,,,,,,,,127.61,,,percent of total billed charges,,,70.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,127.61,,,percent of total billed charges,,,66.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.21,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.61,,,percent of total billed charges,,
NOREPINEPHRINE 8 MG NS 250ML,2500014547,CDM,250,RC,,,,,,,,outpatient,facility,250,UN,127.61,127.61,10.21,618.77,,74.52,,,percent of total billed charges,,,24.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,127.61,,,percent of total billed charges,,,112.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,112.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,112.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,46.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,114.85,,,percent of total billed charges,,,,,,,,,127.61,,,percent of total billed charges,,,86.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.54,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.98,,,percent of total billed charges,,,48.34,,,percent of total billed charges,,,66.09,,,percent of total billed charges,,,,,,,,,,,,,,,25.52,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,51.04,,,percent of total billed charges,,,51.04,,,percent of total billed charges,,,127.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,127.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.21,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,127.61,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,,,,,,,127.61,,,fee schedule,,,51.04,,,percent of total billed charges,,,,,,,,,,,,,,,51.04,,,percent of total billed charges,,,51.04,,,percent of total billed charges,,,51.04,,,percent of total billed charges,,,95.71,,,percent of total billed charges,,,127.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,127.61,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,89.61,,,percent of total billed charges,,
NOREPINEPHRINE 8 MG NS 250ML,2500014547,CDM,250,RC,999,EAPG,,,,,,outpatient,facility,250,UN,127.61,127.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NORETHINDRONE ACET 5 MG TAB,2500014550,CDM,637,RC,6846230450,NDC,,,,,,inpatient,facility,5,UN,8.75,8.75,0.7,8.75,,,,,,,,,,,,,,8.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.88,,,percent of total billed charges,,,,,,,,,8.75,,,percent of total billed charges,,,4.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.75,,,percent of total billed charges,,,,,,,,,,,,,,,8.75,,,percent of total billed charges,,,4.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,
NORETHINDRONE ACET 5 MG TAB,2500014550,CDM,637,RC,6846230450,NDC,,,,,,outpatient,facility,5,UN,8.75,8.75,0.7,618.77,,5.11,,,percent of total billed charges,,,1.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.75,,,percent of total billed charges,,,7.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.88,,,percent of total billed charges,,,,,,,,,8.75,,,percent of total billed charges,,,5.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.72,,,percent of total billed charges,,,,,,,,,,,,,,,4.73,,,percent of total billed charges,,,4.73,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.56,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.65,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.24,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,8.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.7,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,,,,,,,,,,,,,8.75,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,,,,,,,8.75,,,fee schedule,,,8.14,,,percent of total billed charges,,,,,,,,,,,,,,,8.14,,,percent of total billed charges,,,8.14,,,percent of total billed charges,,,8.14,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,8.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.75,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.14,,,percent of total billed charges,,
NORETHINDRONE ACET 5 MG TAB,2500014550,CDM,637,RC,6846230450,NDC,999,EAPG,,,,outpatient,facility,5,UN,8.75,8.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NORTRIPTYLINE HCL 10 MG CAP,2500014570,CDM,637,RC,5167240011,NDC,,,,,,inpatient,facility,10,UN,2.41,2.41,0.19,2.41,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,2.41,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,
NORTRIPTYLINE HCL 10 MG CAP,2500014570,CDM,637,RC,5167240011,NDC,,,,,,outpatient,facility,10,UN,2.41,2.41,0.19,618.77,,1.41,,,percent of total billed charges,,,0.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.41,,,percent of total billed charges,,,2.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.17,,,percent of total billed charges,,,,,,,,,2.41,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.89,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,2.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,2.41,,,fee schedule,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,2.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.69,,,percent of total billed charges,,
NORTRIPTYLINE HCL 10 MG CAP,2500014570,CDM,637,RC,5167240011,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.41,2.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NORTRIPTYLINE HCL 25 MG CAP,2500014572,CDM,637,RC,6068729301,NDC,,,,,,inpatient,facility,25,UN,2.9,2.9,0.23,2.9,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,2.9,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,
NORTRIPTYLINE HCL 25 MG CAP,2500014572,CDM,637,RC,6068729301,NDC,,,,,,outpatient,facility,25,UN,2.9,2.9,0.23,618.77,,1.69,,,percent of total billed charges,,,0.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.9,,,percent of total billed charges,,,2.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.61,,,percent of total billed charges,,,,,,,,,2.9,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.07,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,2.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,2.9,,,fee schedule,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.04,,,percent of total billed charges,,
NORTRIPTYLINE HCL 25 MG CAP,2500014572,CDM,637,RC,6068729301,NDC,999,EAPG,,,,outpatient,facility,25,UN,2.9,2.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NYSTATIN 100000 U/GM CR 15GM,2500014590,CDM,637,RC,4580205935,NDC,,,,,,inpatient,facility,15,UN,46.2,46.2,3.7,46.2,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.58,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,25.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,24.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.44,,,percent of total billed charges,,
NYSTATIN 100000 U/GM CR 15GM,2500014590,CDM,637,RC,4580205935,NDC,,,,,,outpatient,facility,15,UN,46.2,46.2,3.7,618.77,,26.98,,,percent of total billed charges,,,9.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,46.2,,,percent of total billed charges,,,40.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,40.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,40.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,41.58,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,31.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.48,,,percent of total billed charges,,,,,,,,,,,,,,,24.95,,,percent of total billed charges,,,24.95,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.09,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.11,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,17.09,,,percent of total billed charges,,,17.09,,,percent of total billed charges,,,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,46.2,,,fee schedule,,,42.98,,,percent of total billed charges,,,,,,,,,,,,,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,46.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,32.44,,,percent of total billed charges,,
NYSTATIN 100000 U/GM CR 15GM,2500014590,CDM,637,RC,4580205935,NDC,999,EAPG,,,,outpatient,facility,15,UN,46.2,46.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NYSTATIN 100000 U/ML SUSP 5ML,2500014593,CDM,637,RC,121086800,NDC,,,,,,inpatient,facility,5,UN,7.49,7.49,0.6,7.49,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.74,,,percent of total billed charges,,,,,,,,,7.49,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,3.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.26,,,percent of total billed charges,,
NYSTATIN 100000 U/ML SUSP 5ML,2500014593,CDM,637,RC,121086800,NDC,,,,,,outpatient,facility,5,UN,7.49,7.49,0.6,618.77,,4.37,,,percent of total billed charges,,,1.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.49,,,percent of total billed charges,,,6.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.74,,,percent of total billed charges,,,,,,,,,7.49,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.75,,,percent of total billed charges,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.91,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.69,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,3.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,7.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.6,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,7.49,,,fee schedule,,,6.97,,,percent of total billed charges,,,,,,,,,,,,,,,6.97,,,percent of total billed charges,,,6.97,,,percent of total billed charges,,,6.97,,,percent of total billed charges,,,5.62,,,percent of total billed charges,,,7.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.26,,,percent of total billed charges,,
NYSTATIN 100000 U/ML SUSP 5ML,2500014593,CDM,637,RC,121086800,NDC,999,EAPG,,,,outpatient,facility,5,UN,7.49,7.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NYSTATIN/TRIAMCINOL CR 30 GM,2500014601,CDM,637,RC,6846231435,NDC,,,,,,inpatient,facility,30,UN,526.42,526.42,42.11,526.42,,,,,,,,,,,,,,526.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.78,,,percent of total billed charges,,,,,,,,,526.42,,,percent of total billed charges,,,291.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.42,,,percent of total billed charges,,,,,,,,,,,,,,,526.42,,,percent of total billed charges,,,274.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.11,,,percent of total billed charges,,,526.42,,,percent of total billed charges,,,526.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,526.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,369.65,,,percent of total billed charges,,
NYSTATIN/TRIAMCINOL CR 30 GM,2500014601,CDM,637,RC,6846231435,NDC,,,,,,outpatient,facility,30,UN,526.42,526.42,42.11,618.77,,307.43,,,percent of total billed charges,,,102.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,526.42,,,percent of total billed charges,,,463.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,463.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,463.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,526.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,192.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,473.78,,,percent of total billed charges,,,,,,,,,526.42,,,percent of total billed charges,,,356.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.29,,,percent of total billed charges,,,,,,,,,,,,,,,284.27,,,percent of total billed charges,,,284.27,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,526.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,274.48,,,percent of total billed charges,,,526.42,,,percent of total billed charges,,,526.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.08,,,percent of total billed charges,,,199.41,,,percent of total billed charges,,,272.63,,,percent of total billed charges,,,,,,,,,,,,,,,105.28,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,194.78,,,percent of total billed charges,,,194.78,,,percent of total billed charges,,,526.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,526.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,42.11,,,percent of total billed charges,,,526.42,,,percent of total billed charges,,,526.42,,,percent of total billed charges,,,,,,,,,,,,,,,526.42,,,percent of total billed charges,,,526.42,,,percent of total billed charges,,,,,,,,,526.42,,,fee schedule,,,489.68,,,percent of total billed charges,,,,,,,,,,,,,,,489.68,,,percent of total billed charges,,,489.68,,,percent of total billed charges,,,489.68,,,percent of total billed charges,,,394.81,,,percent of total billed charges,,,526.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,526.42,,,percent of total billed charges,,,526.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,369.65,,,percent of total billed charges,,
NYSTATIN/TRIAMCINOL CR 30 GM,2500014601,CDM,637,RC,6846231435,NDC,999,EAPG,,,,outpatient,facility,30,UN,526.42,526.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OFLOXACIN 0.3  OPH 5 ML,2500014610,CDM,637,RC,6498051505,NDC,,,,,,inpatient,facility,5,UN,25.54,25.54,2.04,25.54,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.99,,,percent of total billed charges,,,,,,,,,25.54,,,percent of total billed charges,,,14.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,13.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.93,,,percent of total billed charges,,
OFLOXACIN 0.3  OPH 5 ML,2500014610,CDM,637,RC,6498051505,NDC,,,,,,outpatient,facility,5,UN,25.54,25.54,2.04,618.77,,14.92,,,percent of total billed charges,,,4.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,25.54,,,percent of total billed charges,,,22.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,22.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,22.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22.99,,,percent of total billed charges,,,,,,,,,25.54,,,percent of total billed charges,,,17.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.61,,,percent of total billed charges,,,,,,,,,,,,,,,13.79,,,percent of total billed charges,,,13.79,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.32,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.41,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,13.23,,,percent of total billed charges,,,,,,,,,,,,,,,5.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,9.45,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.04,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,25.54,,,fee schedule,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,19.16,,,percent of total billed charges,,,25.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.93,,,percent of total billed charges,,
OFLOXACIN 0.3  OPH 5 ML,2500014610,CDM,637,RC,6498051505,NDC,999,EAPG,,,,outpatient,facility,5,UN,25.54,25.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OFLOXACIN 0.3 OTIC 10 ML,2500014616,CDM,637,RC,6050503632,NDC,,,,,,inpatient,facility,10,UN,1018.25,1018.25,81.46,1018.25,,,,,,,,,,,,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,916.43,,,percent of total billed charges,,,,,,,,,1018.25,,,percent of total billed charges,,,563.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,1018.25,,,percent of total billed charges,,,530.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,203.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.46,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,715.02,,,percent of total billed charges,,
OFLOXACIN 0.3 OTIC 10 ML,2500014616,CDM,637,RC,6050503632,NDC,,,,,,outpatient,facility,10,UN,1018.25,1018.25,81.46,1018.25,,594.66,,,percent of total billed charges,,,198.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1018.25,,,percent of total billed charges,,,896.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,896.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,896.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,372.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,916.43,,,percent of total billed charges,,,,,,,,,1018.25,,,percent of total billed charges,,,689.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,782.02,,,percent of total billed charges,,,,,,,,,,,,,,,549.86,,,percent of total billed charges,,,549.86,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,530.92,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.87,,,percent of total billed charges,,,385.71,,,percent of total billed charges,,,527.35,,,percent of total billed charges,,,,,,,,,,,,,,,203.65,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,376.75,,,percent of total billed charges,,,376.75,,,percent of total billed charges,,,1018.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1018.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,81.46,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,1018.25,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,,,,,,,1018.25,,,fee schedule,,,947.18,,,percent of total billed charges,,,,,,,,,,,,,,,947.18,,,percent of total billed charges,,,947.18,,,percent of total billed charges,,,947.18,,,percent of total billed charges,,,763.69,,,percent of total billed charges,,,1018.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1018.25,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,509.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,715.02,,,percent of total billed charges,,
OFLOXACIN 0.3 OTIC 10 ML,2500014616,CDM,637,RC,6050503632,NDC,999,EAPG,,,,outpatient,facility,10,UN,1018.25,1018.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OLANZAPINE 10 MG DIS TAB,2500014620,CDM,637,RC,3334208407,NDC,,,,,,inpatient,facility,10,UN,68.21,68.21,5.46,68.21,,,,,,,,,,,,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.39,,,percent of total billed charges,,,,,,,,,68.21,,,percent of total billed charges,,,37.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,68.21,,,percent of total billed charges,,,35.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.9,,,percent of total billed charges,,
OLANZAPINE 10 MG DIS TAB,2500014620,CDM,637,RC,3334208407,NDC,,,,,,outpatient,facility,10,UN,68.21,68.21,5.46,618.77,,39.83,,,percent of total billed charges,,,13.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,68.21,,,percent of total billed charges,,,60.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,60.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,60.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,24.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,61.39,,,percent of total billed charges,,,,,,,,,68.21,,,percent of total billed charges,,,46.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.39,,,percent of total billed charges,,,,,,,,,,,,,,,36.83,,,percent of total billed charges,,,36.83,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.56,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.84,,,percent of total billed charges,,,25.84,,,percent of total billed charges,,,35.33,,,percent of total billed charges,,,,,,,,,,,,,,,13.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,25.24,,,percent of total billed charges,,,25.24,,,percent of total billed charges,,,68.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,68.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.46,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,68.21,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,,,,,,,68.21,,,fee schedule,,,63.45,,,percent of total billed charges,,,,,,,,,,,,,,,63.45,,,percent of total billed charges,,,63.45,,,percent of total billed charges,,,63.45,,,percent of total billed charges,,,51.16,,,percent of total billed charges,,,68.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,68.21,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,47.9,,,percent of total billed charges,,
OLANZAPINE 10 MG DIS TAB,2500014620,CDM,637,RC,3334208407,NDC,999,EAPG,,,,outpatient,facility,10,UN,68.21,68.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OLANZAPINE 10 MG TAB,2500014621,CDM,637,RC,904637661,NDC,,,,,,inpatient,facility,10,UN,1.58,1.58,0.13,1.58,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,1.58,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,
OLANZAPINE 10 MG TAB,2500014621,CDM,637,RC,904637661,NDC,,,,,,outpatient,facility,10,UN,1.58,1.58,0.13,618.77,,0.92,,,percent of total billed charges,,,0.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.58,,,percent of total billed charges,,,1.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.42,,,percent of total billed charges,,,,,,,,,1.58,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,1.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,1.58,,,fee schedule,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.11,,,percent of total billed charges,,
OLANZAPINE 10 MG TAB,2500014621,CDM,637,RC,904637661,NDC,999,EAPG,,,,outpatient,facility,10,UN,1.58,1.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OLANZAPINE 2.5 MG TAB,2500014622,CDM,637,RC,904628361,NDC,,,,,,inpatient,facility,2.5,UN,1.16,1.16,0.09,1.16,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,1.16,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,
OLANZAPINE 2.5 MG TAB,2500014622,CDM,637,RC,904628361,NDC,,,,,,outpatient,facility,2.5,UN,1.16,1.16,0.09,618.77,,0.68,,,percent of total billed charges,,,0.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.16,,,percent of total billed charges,,,1.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.04,,,percent of total billed charges,,,,,,,,,1.16,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,1.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,1.16,,,fee schedule,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,1.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.81,,,percent of total billed charges,,
OLANZAPINE 2.5 MG TAB,2500014622,CDM,637,RC,904628361,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,1.16,1.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OLANZAPINE 5 MG DIS TAB,2500014623,CDM,637,RC,3334208307,NDC,,,,,,inpatient,facility,5,UN,46.2,46.2,3.7,46.2,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.58,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,25.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,24.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.44,,,percent of total billed charges,,
OLANZAPINE 5 MG DIS TAB,2500014623,CDM,637,RC,3334208307,NDC,,,,,,outpatient,facility,5,UN,46.2,46.2,3.7,618.77,,26.98,,,percent of total billed charges,,,9.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,46.2,,,percent of total billed charges,,,40.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,40.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,40.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,41.58,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,31.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.48,,,percent of total billed charges,,,,,,,,,,,,,,,24.95,,,percent of total billed charges,,,24.95,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.09,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.11,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,17.09,,,percent of total billed charges,,,17.09,,,percent of total billed charges,,,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,46.2,,,fee schedule,,,42.98,,,percent of total billed charges,,,,,,,,,,,,,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,46.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,32.44,,,percent of total billed charges,,
OLANZAPINE 5 MG DIS TAB,2500014623,CDM,637,RC,3334208307,NDC,999,EAPG,,,,outpatient,facility,5,UN,46.2,46.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OLANZAPINE 5 MG TAB,2500014624,CDM,637,RC,904637761,NDC,,,,,,inpatient,facility,5,UN,1.18,1.18,0.09,1.18,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,
OLANZAPINE 5 MG TAB,2500014624,CDM,637,RC,904637761,NDC,,,,,,outpatient,facility,5,UN,1.18,1.18,0.09,618.77,,0.69,,,percent of total billed charges,,,0.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.18,,,percent of total billed charges,,,1.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.06,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.44,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,1.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,1.18,,,fee schedule,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,1.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.83,,,percent of total billed charges,,
OLANZAPINE 5 MG TAB,2500014624,CDM,637,RC,904637761,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.18,1.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OLANZAPINE 10 MG INJ,2500014629,CDM,250,RC,J3490,HCPCS,781315972,NDC,,,,inpatient,facility,10,UN,136.95,136.95,10.96,136.95,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.25,,,percent of total billed charges,,,,,,,,,136.95,,,percent of total billed charges,,,75.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,71.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.96,,,percent of total billed charges,,,136.95,,,percent of total billed charges,,,136.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.17,,,percent of total billed charges,,
OLANZAPINE 10 MG INJ,2500014629,CDM,250,RC,J3490,HCPCS,781315972,NDC,,,,outpatient,facility,10,UN,136.95,136.95,1.2,618.77,,79.98,,,percent of total billed charges,,,26.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,136.95,,,percent of total billed charges,,,120.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,120.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,120.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,50.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,123.25,,,percent of total billed charges,,,,,,,,,136.95,,,percent of total billed charges,,,92.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.18,,,percent of total billed charges,,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,136.95,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,136.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.41,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.08,,,percent of total billed charges,,,51.88,,,percent of total billed charges,,,70.93,,,percent of total billed charges,,,,,,,,,,,,,,,27.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,136.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,136.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.96,,,percent of total billed charges,,,136.95,,,percent of total billed charges,,,136.95,,,percent of total billed charges,,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,136.95,,,percent of total billed charges,,,,,,,,,136.95,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,102.71,,,percent of total billed charges,,,136.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,136.95,,,percent of total billed charges,,,136.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,96.17,,,percent of total billed charges,,
OLANZAPINE 10 MG INJ,2500014629,CDM,250,RC,J3490,HCPCS,781315972,NDC,435,EAPG,,outpatient,facility,10,UN,136.95,136.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OSELTAMIVIR 75 MG CAP,2500014690,CDM,637,RC,6818067711,NDC,,,,,,inpatient,facility,75,UN,51.02,51.02,4.08,51.02,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.92,,,percent of total billed charges,,,,,,,,,51.02,,,percent of total billed charges,,,28.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,26.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.08,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.83,,,percent of total billed charges,,
OSELTAMIVIR 75 MG CAP,2500014690,CDM,637,RC,6818067711,NDC,,,,,,outpatient,facility,75,UN,51.02,51.02,4.08,618.77,,29.8,,,percent of total billed charges,,,9.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,51.02,,,percent of total billed charges,,,44.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,44.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,44.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,18.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,45.92,,,percent of total billed charges,,,,,,,,,51.02,,,percent of total billed charges,,,34.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.18,,,percent of total billed charges,,,,,,,,,,,,,,,27.55,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.6,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.78,,,percent of total billed charges,,,19.33,,,percent of total billed charges,,,26.42,,,percent of total billed charges,,,,,,,,,,,,,,,10.2,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,18.88,,,percent of total billed charges,,,18.88,,,percent of total billed charges,,,51.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.08,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,51.02,,,fee schedule,,,47.46,,,percent of total billed charges,,,,,,,,,,,,,,,47.46,,,percent of total billed charges,,,47.46,,,percent of total billed charges,,,47.46,,,percent of total billed charges,,,38.27,,,percent of total billed charges,,,51.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.83,,,percent of total billed charges,,
OSELTAMIVIR 75 MG CAP,2500014690,CDM,637,RC,6818067711,NDC,999,EAPG,,,,outpatient,facility,75,UN,51.02,51.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OSELTAMIVIR 30 MG CAP,2500014691,CDM,637,RC,6818067511,NDC,,,,,,inpatient,facility,30,UN,46.79,46.79,3.74,46.79,,,,,,,,,,,,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.11,,,percent of total billed charges,,,,,,,,,46.79,,,percent of total billed charges,,,25.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,46.79,,,percent of total billed charges,,,24.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.86,,,percent of total billed charges,,
OSELTAMIVIR 30 MG CAP,2500014691,CDM,637,RC,6818067511,NDC,,,,,,outpatient,facility,30,UN,46.79,46.79,3.74,618.77,,27.33,,,percent of total billed charges,,,9.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,46.79,,,percent of total billed charges,,,41.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,41.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,41.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,42.11,,,percent of total billed charges,,,,,,,,,46.79,,,percent of total billed charges,,,31.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.93,,,percent of total billed charges,,,,,,,,,,,,,,,25.27,,,percent of total billed charges,,,25.27,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.4,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.56,,,percent of total billed charges,,,17.72,,,percent of total billed charges,,,24.23,,,percent of total billed charges,,,,,,,,,,,,,,,9.36,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,17.31,,,percent of total billed charges,,,17.31,,,percent of total billed charges,,,46.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.74,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,46.79,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,,,,,,,46.79,,,fee schedule,,,43.52,,,percent of total billed charges,,,,,,,,,,,,,,,43.52,,,percent of total billed charges,,,43.52,,,percent of total billed charges,,,43.52,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,46.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,46.79,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,32.86,,,percent of total billed charges,,
OSELTAMIVIR 30 MG CAP,2500014691,CDM,637,RC,6818067511,NDC,999,EAPG,,,,outpatient,facility,30,UN,46.79,46.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXAZEPAM 10 MG CAP,2500014730,CDM,637,RC,6258481201,NDC,,,,,,inpatient,facility,10,UN,9.44,9.44,0.76,9.44,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.5,,,percent of total billed charges,,,,,,,,,9.44,,,percent of total billed charges,,,5.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,
OXAZEPAM 10 MG CAP,2500014730,CDM,637,RC,6258481201,NDC,,,,,,outpatient,facility,10,UN,9.44,9.44,0.76,618.77,,5.51,,,percent of total billed charges,,,1.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.44,,,percent of total billed charges,,,8.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,8.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,8.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.5,,,percent of total billed charges,,,,,,,,,9.44,,,percent of total billed charges,,,6.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,5.1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.17,,,percent of total billed charges,,,3.58,,,percent of total billed charges,,,4.89,,,percent of total billed charges,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.49,,,percent of total billed charges,,,3.49,,,percent of total billed charges,,,9.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.76,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,9.44,,,fee schedule,,,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,7.08,,,percent of total billed charges,,,9.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.44,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.63,,,percent of total billed charges,,
OXAZEPAM 10 MG CAP,2500014730,CDM,637,RC,6258481201,NDC,999,EAPG,,,,outpatient,facility,10,UN,9.44,9.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXAZEPAM 15 MG CAP,2500014732,CDM,637,RC,6258481301,NDC,,,,,,inpatient,facility,15,UN,10.39,10.39,0.83,10.39,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.35,,,percent of total billed charges,,,,,,,,,10.39,,,percent of total billed charges,,,5.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,5.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.3,,,percent of total billed charges,,
OXAZEPAM 15 MG CAP,2500014732,CDM,637,RC,6258481301,NDC,,,,,,outpatient,facility,15,UN,10.39,10.39,0.83,618.77,,6.07,,,percent of total billed charges,,,2.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.39,,,percent of total billed charges,,,9.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,9.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,9.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.35,,,percent of total billed charges,,,,,,,,,10.39,,,percent of total billed charges,,,7.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.42,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.9,,,percent of total billed charges,,,3.94,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.84,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,10.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.83,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,,,,,,,10.39,,,fee schedule,,,9.66,,,percent of total billed charges,,,,,,,,,,,,,,,9.66,,,percent of total billed charges,,,9.66,,,percent of total billed charges,,,9.66,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,10.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.39,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.3,,,percent of total billed charges,,
OXAZEPAM 15 MG CAP,2500014732,CDM,637,RC,6258481301,NDC,999,EAPG,,,,outpatient,facility,15,UN,10.39,10.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXCARBAZEPINE 150 MG TAB,2500014740,CDM,637,RC,6808484501,NDC,,,,,,inpatient,facility,150,UN,4.98,4.98,0.4,4.98,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.48,,,percent of total billed charges,,,,,,,,,4.98,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,
OXCARBAZEPINE 150 MG TAB,2500014740,CDM,637,RC,6808484501,NDC,,,,,,outpatient,facility,150,UN,4.98,4.98,0.4,618.77,,2.91,,,percent of total billed charges,,,0.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.98,,,percent of total billed charges,,,4.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.48,,,percent of total billed charges,,,,,,,,,4.98,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,2.69,,,percent of total billed charges,,,2.69,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.78,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,4.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.4,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,4.98,,,fee schedule,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,4.63,,,percent of total billed charges,,,4.63,,,percent of total billed charges,,,3.74,,,percent of total billed charges,,,4.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.98,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.5,,,percent of total billed charges,,
OXCARBAZEPINE 150 MG TAB,2500014740,CDM,637,RC,6808484501,NDC,999,EAPG,,,,outpatient,facility,150,UN,4.98,4.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXCARBAZEPINE 300 MG TAB,2500014742,CDM,637,RC,6808485301,NDC,,,,,,inpatient,facility,300,UN,9.07,9.07,0.73,9.07,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.16,,,percent of total billed charges,,,,,,,,,9.07,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.37,,,percent of total billed charges,,
OXCARBAZEPINE 300 MG TAB,2500014742,CDM,637,RC,6808485301,NDC,,,,,,outpatient,facility,300,UN,9.07,9.07,0.73,618.77,,5.3,,,percent of total billed charges,,,1.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.07,,,percent of total billed charges,,,7.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.16,,,percent of total billed charges,,,,,,,,,9.07,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.97,,,percent of total billed charges,,,,,,,,,,,,,,,4.9,,,percent of total billed charges,,,4.9,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.73,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.89,,,percent of total billed charges,,,3.44,,,percent of total billed charges,,,4.7,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,9.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.73,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,,,,,,,9.07,,,fee schedule,,,8.44,,,percent of total billed charges,,,,,,,,,,,,,,,8.44,,,percent of total billed charges,,,8.44,,,percent of total billed charges,,,8.44,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,9.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.07,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.37,,,percent of total billed charges,,
OXCARBAZEPINE 300 MG TAB,2500014742,CDM,637,RC,6808485301,NDC,999,EAPG,,,,outpatient,facility,300,UN,9.07,9.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXCARBAZEPINE 300 MG/5ML UDC,2500014744,CDM,637,RC,6809412362,NDC,,,,,,inpatient,facility,5,UN,28.77,28.77,2.3,28.77,,,,,,,,,,,,,,28.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.89,,,percent of total billed charges,,,,,,,,,28.77,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.77,,,percent of total billed charges,,,,,,,,,,,,,,,28.77,,,percent of total billed charges,,,15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,28.77,,,percent of total billed charges,,,28.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,
OXCARBAZEPINE 300 MG/5ML UDC,2500014744,CDM,637,RC,6809412362,NDC,,,,,,outpatient,facility,5,UN,28.77,28.77,2.3,618.77,,16.8,,,percent of total billed charges,,,5.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,28.77,,,percent of total billed charges,,,25.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,25.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,25.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,28.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,25.89,,,percent of total billed charges,,,,,,,,,28.77,,,percent of total billed charges,,,19.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,15.54,,,percent of total billed charges,,,15.54,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,28.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15,,,percent of total billed charges,,,28.77,,,percent of total billed charges,,,28.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.87,,,percent of total billed charges,,,10.9,,,percent of total billed charges,,,14.9,,,percent of total billed charges,,,,,,,,,,,,,,,5.75,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.64,,,percent of total billed charges,,,10.64,,,percent of total billed charges,,,28.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.3,,,percent of total billed charges,,,28.77,,,percent of total billed charges,,,28.77,,,percent of total billed charges,,,,,,,,,,,,,,,28.77,,,percent of total billed charges,,,28.77,,,percent of total billed charges,,,,,,,,,28.77,,,fee schedule,,,26.76,,,percent of total billed charges,,,,,,,,,,,,,,,26.76,,,percent of total billed charges,,,26.76,,,percent of total billed charges,,,26.76,,,percent of total billed charges,,,21.58,,,percent of total billed charges,,,28.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,28.77,,,percent of total billed charges,,,28.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.2,,,percent of total billed charges,,
OXCARBAZEPINE 300 MG/5ML UDC,2500014744,CDM,637,RC,6809412362,NDC,999,EAPG,,,,outpatient,facility,5,UN,28.77,28.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYBUTYNIN 5 MG TAB,2500014760,CDM,637,RC,832003801,NDC,,,,,,inpatient,facility,5,UN,2.18,2.18,0.17,2.18,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,
OXYBUTYNIN 5 MG TAB,2500014760,CDM,637,RC,832003801,NDC,,,,,,outpatient,facility,5,UN,2.18,2.18,0.17,618.77,,1.27,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.18,,,percent of total billed charges,,,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.96,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.81,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,2.18,,,fee schedule,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,2.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.53,,,percent of total billed charges,,
OXYBUTYNIN 5 MG TAB,2500014760,CDM,637,RC,832003801,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.18,2.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYCODONE 10 MG TABCR,2500014770,CDM,637,RC,5901141020,NDC,,,,,,inpatient,facility,10,UN,18.05,18.05,1.44,18.05,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.25,,,percent of total billed charges,,,,,,,,,18.05,,,percent of total billed charges,,,9.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,9.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.67,,,percent of total billed charges,,
OXYCODONE 10 MG TABCR,2500014770,CDM,637,RC,5901141020,NDC,,,,,,outpatient,facility,10,UN,18.05,18.05,1.44,618.77,,10.54,,,percent of total billed charges,,,3.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,18.05,,,percent of total billed charges,,,15.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,15.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,15.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,16.25,,,percent of total billed charges,,,,,,,,,18.05,,,percent of total billed charges,,,12.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.86,,,percent of total billed charges,,,,,,,,,,,,,,,9.75,,,percent of total billed charges,,,9.75,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.41,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,9.35,,,percent of total billed charges,,,,,,,,,,,,,,,3.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.68,,,percent of total billed charges,,,6.68,,,percent of total billed charges,,,18.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.44,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,18.05,,,fee schedule,,,16.79,,,percent of total billed charges,,,,,,,,,,,,,,,16.79,,,percent of total billed charges,,,16.79,,,percent of total billed charges,,,16.79,,,percent of total billed charges,,,13.54,,,percent of total billed charges,,,18.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,12.67,,,percent of total billed charges,,
OXYCODONE 10 MG TABCR,2500014770,CDM,637,RC,5901141020,NDC,999,EAPG,,,,outpatient,facility,10,UN,18.05,18.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYCODONE 20 MG TABCR,2500014771,CDM,637,RC,5901142020,NDC,,,,,,inpatient,facility,20,UN,33.66,33.66,2.69,33.66,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.29,,,percent of total billed charges,,,,,,,,,33.66,,,percent of total billed charges,,,18.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.69,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.64,,,percent of total billed charges,,
OXYCODONE 20 MG TABCR,2500014771,CDM,637,RC,5901142020,NDC,,,,,,outpatient,facility,20,UN,33.66,33.66,2.69,618.77,,19.66,,,percent of total billed charges,,,6.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,33.66,,,percent of total billed charges,,,29.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,29.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,29.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,12.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,30.29,,,percent of total billed charges,,,,,,,,,33.66,,,percent of total billed charges,,,22.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.85,,,percent of total billed charges,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.55,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.58,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,17.43,,,percent of total billed charges,,,,,,,,,,,,,,,6.73,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,12.45,,,percent of total billed charges,,,12.45,,,percent of total billed charges,,,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.69,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,,,,,,,33.66,,,fee schedule,,,31.31,,,percent of total billed charges,,,,,,,,,,,,,,,31.31,,,percent of total billed charges,,,31.31,,,percent of total billed charges,,,31.31,,,percent of total billed charges,,,25.24,,,percent of total billed charges,,,33.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,33.66,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,23.64,,,percent of total billed charges,,
OXYCODONE 20 MG TABCR,2500014771,CDM,637,RC,5901142020,NDC,999,EAPG,,,,outpatient,facility,20,UN,33.66,33.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYCODONE 5 MG CAP,2500014773,CDM,637,RC,6255916701,NDC,,,,,,inpatient,facility,5,UN,6.07,6.07,0.49,6.07,,,,,,,,,,,,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,,,,,,,6.07,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,6.07,,,percent of total billed charges,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,
OXYCODONE 5 MG CAP,2500014773,CDM,637,RC,6255916701,NDC,,,,,,outpatient,facility,5,UN,6.07,6.07,0.49,618.77,,3.54,,,percent of total billed charges,,,1.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.07,,,percent of total billed charges,,,5.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.46,,,percent of total billed charges,,,,,,,,,6.07,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.66,,,percent of total billed charges,,,,,,,,,,,,,,,3.28,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.61,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.25,,,percent of total billed charges,,,2.25,,,percent of total billed charges,,,6.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.49,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,6.07,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,,,,,,,6.07,,,fee schedule,,,5.65,,,percent of total billed charges,,,,,,,,,,,,,,,5.65,,,percent of total billed charges,,,5.65,,,percent of total billed charges,,,5.65,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,6.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.07,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.26,,,percent of total billed charges,,
OXYCODONE 5 MG CAP,2500014773,CDM,637,RC,6255916701,NDC,999,EAPG,,,,outpatient,facility,5,UN,6.07,6.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYCODONE 5 MG TAB IR,2500014774,CDM,637,RC,904696661,NDC,,,,,,inpatient,facility,5,UN,1.09,1.09,0.09,1.09,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,
OXYCODONE 5 MG TAB IR,2500014774,CDM,637,RC,904696661,NDC,,,,,,outpatient,facility,5,UN,1.09,1.09,0.09,618.77,,0.64,,,percent of total billed charges,,,0.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.09,,,percent of total billed charges,,,0.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.98,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,1.09,,,fee schedule,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,1.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.77,,,percent of total billed charges,,
OXYCODONE 5 MG TAB IR,2500014774,CDM,637,RC,904696661,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.09,1.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYCODONE 5 MG/5 ML UDC,2500014775,CDM,637,RC,904682894,NDC,,,,,,inpatient,facility,5,UN,14.49,14.49,1.16,14.49,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,,,,,,,14.49,,,percent of total billed charges,,,8.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.17,,,percent of total billed charges,,
OXYCODONE 5 MG/5 ML UDC,2500014775,CDM,637,RC,904682894,NDC,,,,,,outpatient,facility,5,UN,14.49,14.49,1.16,618.77,,8.46,,,percent of total billed charges,,,2.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.49,,,percent of total billed charges,,,12.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.04,,,percent of total billed charges,,,,,,,,,14.49,,,percent of total billed charges,,,9.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.13,,,percent of total billed charges,,,,,,,,,,,,,,,7.82,,,percent of total billed charges,,,7.82,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.01,,,percent of total billed charges,,,5.49,,,percent of total billed charges,,,7.5,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.36,,,percent of total billed charges,,,5.36,,,percent of total billed charges,,,14.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.16,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,14.49,,,fee schedule,,,13.48,,,percent of total billed charges,,,,,,,,,,,,,,,13.48,,,percent of total billed charges,,,13.48,,,percent of total billed charges,,,13.48,,,percent of total billed charges,,,10.87,,,percent of total billed charges,,,14.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.17,,,percent of total billed charges,,
OXYCODONE 5 MG/5 ML UDC,2500014775,CDM,637,RC,904682894,NDC,999,EAPG,,,,outpatient,facility,5,UN,14.49,14.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYMETAZOLINE 0.05  NASAL 15ML,2500014790,CDM,637,RC,4110081123,NDC,,,,,,inpatient,facility,15,UN,9.16,9.16,0.73,9.16,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.24,,,percent of total billed charges,,,,,,,,,9.16,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,
OXYMETAZOLINE 0.05  NASAL 15ML,2500014790,CDM,637,RC,4110081123,NDC,,,,,,outpatient,facility,15,UN,9.16,9.16,0.73,618.77,,5.35,,,percent of total billed charges,,,1.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.16,,,percent of total billed charges,,,8.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,8.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,8.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.24,,,percent of total billed charges,,,,,,,,,9.16,,,percent of total billed charges,,,6.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,4.74,,,percent of total billed charges,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.39,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,9.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.73,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,,,,,,,9.16,,,fee schedule,,,8.52,,,percent of total billed charges,,,,,,,,,,,,,,,8.52,,,percent of total billed charges,,,8.52,,,percent of total billed charges,,,8.52,,,percent of total billed charges,,,6.87,,,percent of total billed charges,,,9.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.16,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.43,,,percent of total billed charges,,
OXYMETAZOLINE 0.05  NASAL 15ML,2500014790,CDM,637,RC,4110081123,NDC,999,EAPG,,,,outpatient,facility,15,UN,9.16,9.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PANTOPRAZOLE 40 MG TABEC,2500014840,CDM,637,RC,904647461,NDC,,,,,,inpatient,facility,20,UN,0.99,0.99,0.08,0.99,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,
PANTOPRAZOLE 40 MG TABEC,2500014840,CDM,637,RC,904647461,NDC,,,,,,outpatient,facility,20,UN,0.99,0.99,0.08,618.77,,0.58,,,percent of total billed charges,,,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.99,,,percent of total billed charges,,,0.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.89,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,fee schedule,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.7,,,percent of total billed charges,,
PANTOPRAZOLE 40 MG TABEC,2500014840,CDM,637,RC,904647461,NDC,999,EAPG,,,,outpatient,facility,20,UN,0.99,0.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PANTOPRAZOLE 40 MG SUSP PKT,2500014841,CDM,637,RC,6275607164,NDC,,,,,,inpatient,facility,40,UN,46.73,46.73,3.74,46.73,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.06,,,percent of total billed charges,,,,,,,,,46.73,,,percent of total billed charges,,,25.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,24.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.81,,,percent of total billed charges,,
PANTOPRAZOLE 40 MG SUSP PKT,2500014841,CDM,637,RC,6275607164,NDC,,,,,,outpatient,facility,40,UN,46.73,46.73,3.74,618.77,,27.29,,,percent of total billed charges,,,9.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,46.73,,,percent of total billed charges,,,41.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,41.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,41.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,42.06,,,percent of total billed charges,,,,,,,,,46.73,,,percent of total billed charges,,,31.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.89,,,percent of total billed charges,,,,,,,,,,,,,,,25.23,,,percent of total billed charges,,,25.23,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.37,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.51,,,percent of total billed charges,,,17.7,,,percent of total billed charges,,,24.2,,,percent of total billed charges,,,,,,,,,,,,,,,9.35,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,17.29,,,percent of total billed charges,,,17.29,,,percent of total billed charges,,,46.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.74,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,,,,,,,46.73,,,fee schedule,,,43.47,,,percent of total billed charges,,,,,,,,,,,,,,,43.47,,,percent of total billed charges,,,43.47,,,percent of total billed charges,,,43.47,,,percent of total billed charges,,,35.05,,,percent of total billed charges,,,46.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,46.73,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,32.81,,,percent of total billed charges,,
PANTOPRAZOLE 40 MG SUSP PKT,2500014841,CDM,637,RC,6275607164,NDC,999,EAPG,,,,outpatient,facility,40,UN,46.73,46.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PANTOPRAZOLE 40 MG/10 ML INJ,2500014843,CDM,636,RC,J2470,HCPCS,5515020210,NDC,,,,inpatient,facility,40,UN,28.05,28.05,2.24,28.05,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.25,,,percent of total billed charges,,,,,,,,,28.05,,,percent of total billed charges,,,15.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,14.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.7,,,percent of total billed charges,,
PANTOPRAZOLE 40 MG/10 ML INJ,2500014843,CDM,636,RC,J2470,HCPCS,5515020210,NDC,,,,outpatient,facility,40,UN,28.05,28.05,2.24,618.77,,16.38,,,percent of total billed charges,,,5.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,28.05,,,percent of total billed charges,,,6.13,,,fee schedule,,,5.91,,,fee schedule,,,,,,,,,5.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,25.25,,,percent of total billed charges,,,,,,,,,28.05,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.54,,,percent of total billed charges,,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,15.15,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.63,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.32,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,14.53,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.38,,,percent of total billed charges,,,10.38,,,percent of total billed charges,,,28.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.24,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,28.05,,,fee schedule,,,26.09,,,percent of total billed charges,,,,,,,,,,,,,,,26.09,,,percent of total billed charges,,,26.09,,,percent of total billed charges,,,26.09,,,percent of total billed charges,,,21.04,,,percent of total billed charges,,,28.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,19.7,,,percent of total billed charges,,
PANTOPRAZOLE 40 MG/10 ML INJ,2500014843,CDM,636,RC,J2470,HCPCS,5515020210,NDC,496,EAPG,,outpatient,facility,40,UN,28.05,28.05,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PAROXETINE HCL 10 MG TAB,2500014940,CDM,637,RC,5026864015,NDC,,,,,,inpatient,facility,10,UN,2.54,2.54,0.2,2.54,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.29,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,
PAROXETINE HCL 10 MG TAB,2500014940,CDM,637,RC,5026864015,NDC,,,,,,outpatient,facility,10,UN,2.54,2.54,0.2,618.77,,1.48,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.54,,,percent of total billed charges,,,2.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.29,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.94,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,2.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,2.54,,,fee schedule,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,2.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.78,,,percent of total billed charges,,
PAROXETINE HCL 10 MG TAB,2500014940,CDM,637,RC,5026864015,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.54,2.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PAROXETINE HCL 20 MG TAB,2500014942,CDM,637,RC,904567761,NDC,,,,,,inpatient,facility,20,UN,0.82,0.82,0.07,0.82,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
PAROXETINE HCL 20 MG TAB,2500014942,CDM,637,RC,904567761,NDC,,,,,,outpatient,facility,20,UN,0.82,0.82,0.07,618.77,,0.48,,,percent of total billed charges,,,0.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.82,,,percent of total billed charges,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.74,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,0.82,,,fee schedule,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.58,,,percent of total billed charges,,
PAROXETINE HCL 20 MG TAB,2500014942,CDM,637,RC,904567761,NDC,999,EAPG,,,,outpatient,facility,20,UN,0.82,0.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATIENT OWN MEDICATION,2500014955,CDM,637,RC,,,,,,,,inpatient,facility,1,UN,313.5,313.5,25.08,313.5,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.15,,,percent of total billed charges,,,,,,,,,313.5,,,percent of total billed charges,,,173.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,286.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,163.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.08,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.14,,,percent of total billed charges,,
PATIENT OWN MEDICATION,2500014955,CDM,637,RC,,,,,,,,outpatient,facility,1,UN,313.5,313.5,25.08,618.77,,183.08,,,percent of total billed charges,,,61.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,313.5,,,percent of total billed charges,,,276.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,276.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,276.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,114.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,282.15,,,percent of total billed charges,,,,,,,,,313.5,,,percent of total billed charges,,,212.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.77,,,percent of total billed charges,,,,,,,,,,,,,,,169.29,,,percent of total billed charges,,,169.29,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,163.46,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.26,,,percent of total billed charges,,,118.75,,,percent of total billed charges,,,162.36,,,percent of total billed charges,,,,,,,,,,,,,,,62.7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,116,,,percent of total billed charges,,,116,,,percent of total billed charges,,,313.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,313.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.08,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,313.5,,,fee schedule,,,291.62,,,percent of total billed charges,,,,,,,,,,,,,,,291.62,,,percent of total billed charges,,,291.62,,,percent of total billed charges,,,291.62,,,percent of total billed charges,,,235.13,,,percent of total billed charges,,,313.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,220.14,,,percent of total billed charges,,
PATIENT OWN MEDICATION,2500014955,CDM,637,RC,999,EAPG,,,,,,outpatient,facility,1,UN,313.5,313.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PENICILLIN VK 250 MG TAB,2500015012,CDM,637,RC,6586217501,NDC,,,,,,inpatient,facility,250,UN,1.52,1.52,0.12,1.52,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,
PENICILLIN VK 250 MG TAB,2500015012,CDM,637,RC,6586217501,NDC,,,,,,outpatient,facility,250,UN,1.52,1.52,0.12,618.77,,0.89,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.52,,,percent of total billed charges,,,1.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.37,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,1.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,1.52,,,fee schedule,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,1.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.07,,,percent of total billed charges,,
PENICILLIN VK 250 MG TAB,2500015012,CDM,637,RC,6586217501,NDC,999,EAPG,,,,outpatient,facility,250,UN,1.52,1.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PENICILLIN VK 250 MG/5 ML,2500015017,CDM,637,RC,93412773,NDC,,,,,,inpatient,facility,5,UN,1.85,1.85,0.15,1.85,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,
PENICILLIN VK 250 MG/5 ML,2500015017,CDM,637,RC,93412773,NDC,,,,,,outpatient,facility,5,UN,1.85,1.85,0.15,618.77,,1.08,,,percent of total billed charges,,,0.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.85,,,percent of total billed charges,,,1.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.67,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,1.85,,,fee schedule,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,1.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.3,,,percent of total billed charges,,
PENICILLIN VK 250 MG/5 ML,2500015017,CDM,637,RC,93412773,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.85,1.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PENTOXIFYLLINE 400 MG TABCR,2500015040,CDM,637,RC,904544861,NDC,,,,,,inpatient,facility,400,UN,0.83,0.83,0.07,0.83,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
PENTOXIFYLLINE 400 MG TABCR,2500015040,CDM,637,RC,904544861,NDC,,,,,,outpatient,facility,400,UN,0.83,0.83,0.07,618.77,,0.48,,,percent of total billed charges,,,0.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.83,,,percent of total billed charges,,,0.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.75,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,0.83,,,fee schedule,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.58,,,percent of total billed charges,,
PENTOXIFYLLINE 400 MG TABCR,2500015040,CDM,637,RC,904544861,NDC,999,EAPG,,,,outpatient,facility,400,UN,0.83,0.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PERMETHRIN 5  CR 60 GM,2500015070,CDM,637,RC,2192202107,NDC,,,,,,inpatient,facility,60,UN,389.4,389.4,31.15,389.4,,,,,,,,,,,,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.46,,,percent of total billed charges,,,,,,,,,389.4,,,percent of total billed charges,,,215.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,389.4,,,percent of total billed charges,,,203.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.15,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,273.44,,,percent of total billed charges,,
PERMETHRIN 5  CR 60 GM,2500015070,CDM,637,RC,2192202107,NDC,,,,,,outpatient,facility,60,UN,389.4,389.4,31.15,618.77,,227.41,,,percent of total billed charges,,,75.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,389.4,,,percent of total billed charges,,,342.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,342.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,342.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,142.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,350.46,,,percent of total billed charges,,,,,,,,,389.4,,,percent of total billed charges,,,263.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.06,,,percent of total billed charges,,,,,,,,,,,,,,,210.28,,,percent of total billed charges,,,210.28,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,203.03,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,295.94,,,percent of total billed charges,,,147.5,,,percent of total billed charges,,,201.67,,,percent of total billed charges,,,,,,,,,,,,,,,77.88,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,144.08,,,percent of total billed charges,,,144.08,,,percent of total billed charges,,,389.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,389.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.15,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,389.4,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,,,,,,,389.4,,,fee schedule,,,362.22,,,percent of total billed charges,,,,,,,,,,,,,,,362.22,,,percent of total billed charges,,,362.22,,,percent of total billed charges,,,362.22,,,percent of total billed charges,,,292.05,,,percent of total billed charges,,,389.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,389.4,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,273.44,,,percent of total billed charges,,
PERMETHRIN 5  CR 60 GM,2500015070,CDM,637,RC,2192202107,NDC,999,EAPG,,,,outpatient,facility,60,UN,389.4,389.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PERMETHRIN CR RINSE 1  60 ML,2500015075,CDM,637,RC,6373612002,NDC,,,,,,inpatient,facility,60,UN,23.76,23.76,1.9,23.76,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.38,,,percent of total billed charges,,,,,,,,,23.76,,,percent of total billed charges,,,13.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,12.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.68,,,percent of total billed charges,,
PERMETHRIN CR RINSE 1  60 ML,2500015075,CDM,637,RC,6373612002,NDC,,,,,,outpatient,facility,60,UN,23.76,23.76,1.9,618.77,,13.88,,,percent of total billed charges,,,4.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,23.76,,,percent of total billed charges,,,20.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,20.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,20.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,21.38,,,percent of total billed charges,,,,,,,,,23.76,,,percent of total billed charges,,,16.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.25,,,percent of total billed charges,,,,,,,,,,,,,,,12.83,,,percent of total billed charges,,,12.83,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.39,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.06,,,percent of total billed charges,,,9,,,percent of total billed charges,,,12.31,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.79,,,percent of total billed charges,,,8.79,,,percent of total billed charges,,,23.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.9,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,,,,,,,23.76,,,fee schedule,,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,22.1,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,23.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,23.76,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,16.68,,,percent of total billed charges,,
PERMETHRIN CR RINSE 1  60 ML,2500015075,CDM,637,RC,6373612002,NDC,999,EAPG,,,,outpatient,facility,60,UN,23.76,23.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PETROLATUM OINT 5 GM PKT,2500015110,CDM,637,RC,6777721101,NDC,,,,,,inpatient,facility,5,UN,0.2,0.2,0.02,0.2,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,0.2,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,
PETROLATUM OINT 5 GM PKT,2500015110,CDM,637,RC,6777721101,NDC,,,,,,outpatient,facility,5,UN,0.2,0.2,0.02,618.77,,0.12,,,percent of total billed charges,,,0.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,0.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.18,,,percent of total billed charges,,,,,,,,,0.2,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,0.08,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.07,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,0.2,,,fee schedule,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,0.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.14,,,percent of total billed charges,,
PETROLATUM OINT 5 GM PKT,2500015110,CDM,637,RC,6777721101,NDC,999,EAPG,,,,outpatient,facility,5,UN,0.2,0.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PETROLATUM OPH OINT 3.5 GM,2500015113,CDM,637,RC,23024004,NDC,,,,,,inpatient,facility,3.5,UN,14.66,14.66,1.17,14.66,,,,,,,,,,,,,,14.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.19,,,percent of total billed charges,,,,,,,,,14.66,,,percent of total billed charges,,,8.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.66,,,percent of total billed charges,,,,,,,,,,,,,,,14.66,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,14.66,,,percent of total billed charges,,,14.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.29,,,percent of total billed charges,,
PETROLATUM OPH OINT 3.5 GM,2500015113,CDM,637,RC,23024004,NDC,,,,,,outpatient,facility,3.5,UN,14.66,14.66,1.17,618.77,,8.56,,,percent of total billed charges,,,2.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.66,,,percent of total billed charges,,,12.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.19,,,percent of total billed charges,,,,,,,,,14.66,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.26,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,14.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,14.66,,,percent of total billed charges,,,14.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.14,,,percent of total billed charges,,,5.55,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.42,,,percent of total billed charges,,,5.42,,,percent of total billed charges,,,14.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.17,,,percent of total billed charges,,,14.66,,,percent of total billed charges,,,14.66,,,percent of total billed charges,,,,,,,,,,,,,,,14.66,,,percent of total billed charges,,,14.66,,,percent of total billed charges,,,,,,,,,14.66,,,fee schedule,,,13.64,,,percent of total billed charges,,,,,,,,,,,,,,,13.64,,,percent of total billed charges,,,13.64,,,percent of total billed charges,,,13.64,,,percent of total billed charges,,,11,,,percent of total billed charges,,,14.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.66,,,percent of total billed charges,,,14.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.33,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.29,,,percent of total billed charges,,
PETROLATUM OPH OINT 3.5 GM,2500015113,CDM,637,RC,23024004,NDC,999,EAPG,,,,outpatient,facility,3.5,UN,14.66,14.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENAZOPYRIDINE HCL 100 MG TAB,2500015120,CDM,637,RC,7582611410,NDC,,,,,,inpatient,facility,100,UN,7.92,7.92,0.63,7.92,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,7.92,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.56,,,percent of total billed charges,,
PHENAZOPYRIDINE HCL 100 MG TAB,2500015120,CDM,637,RC,7582611410,NDC,,,,,,outpatient,facility,100,UN,7.92,7.92,0.63,618.77,,4.63,,,percent of total billed charges,,,1.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.92,,,percent of total billed charges,,,6.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.13,,,percent of total billed charges,,,,,,,,,7.92,,,percent of total billed charges,,,5.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.08,,,percent of total billed charges,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,4.28,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,3,,,percent of total billed charges,,,4.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,7.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.63,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,7.92,,,fee schedule,,,7.37,,,percent of total billed charges,,,,,,,,,,,,,,,7.37,,,percent of total billed charges,,,7.37,,,percent of total billed charges,,,7.37,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,7.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.56,,,percent of total billed charges,,
PHENAZOPYRIDINE HCL 100 MG TAB,2500015120,CDM,637,RC,7582611410,NDC,999,EAPG,,,,outpatient,facility,100,UN,7.92,7.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENOBARBITAL 100 MG TAB,2500015140,CDM,637,RC,1351710716,NDC,,,,,,inpatient,facility,20,UN,2.05,2.05,0.16,2.05,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,2.05,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,
PHENOBARBITAL 100 MG TAB,2500015140,CDM,637,RC,1351710716,NDC,,,,,,outpatient,facility,20,UN,2.05,2.05,0.16,618.77,,1.2,,,percent of total billed charges,,,0.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.05,,,percent of total billed charges,,,1.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.84,,,percent of total billed charges,,,,,,,,,2.05,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,2.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,2.05,,,fee schedule,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,2.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.05,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.44,,,percent of total billed charges,,
PHENOBARBITAL 100 MG TAB,2500015140,CDM,637,RC,1351710716,NDC,999,EAPG,,,,outpatient,facility,20,UN,2.05,2.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENOBARBITAL 15 MG TAB,2500015141,CDM,637,RC,143149505,NDC,,,,,,inpatient,facility,15,UN,0.56,0.56,0.04,0.56,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,
PHENOBARBITAL 15 MG TAB,2500015141,CDM,637,RC,143149505,NDC,,,,,,outpatient,facility,15,UN,0.56,0.56,0.04,618.77,,0.33,,,percent of total billed charges,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.5,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.56,,,fee schedule,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,0.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.39,,,percent of total billed charges,,
PHENOBARBITAL 15 MG TAB,2500015141,CDM,637,RC,143149505,NDC,999,EAPG,,,,outpatient,facility,15,UN,0.56,0.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENOBARBITAL 20 MG/5 ML UDC,2500015146,CDM,637,RC,1657167516,NDC,,,,,,inpatient,facility,5,UN,3.37,3.37,0.27,3.37,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,,,,,,,3.37,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,
PHENOBARBITAL 20 MG/5 ML UDC,2500015146,CDM,637,RC,1657167516,NDC,,,,,,outpatient,facility,5,UN,3.37,3.37,0.27,618.77,,1.97,,,percent of total billed charges,,,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.37,,,percent of total billed charges,,,2.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.03,,,percent of total billed charges,,,,,,,,,3.37,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,3.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.27,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,3.37,,,fee schedule,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,2.53,,,percent of total billed charges,,,3.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.37,,,percent of total billed charges,,
PHENOBARBITAL 20 MG/5 ML UDC,2500015146,CDM,637,RC,1657167516,NDC,999,EAPG,,,,outpatient,facility,5,UN,3.37,3.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENOL 1.4  SOLN 180 ML,2500015150,CDM,637,RC,904630521,NDC,,,,,,inpatient,facility,180,UN,3.68,3.68,0.29,3.68,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,,,,,,,3.68,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,
PHENOL 1.4  SOLN 180 ML,2500015150,CDM,637,RC,904630521,NDC,,,,,,outpatient,facility,180,UN,3.68,3.68,0.29,618.77,,2.15,,,percent of total billed charges,,,0.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.68,,,percent of total billed charges,,,3.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.31,,,percent of total billed charges,,,,,,,,,3.68,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.36,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,3.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.29,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,,,,,,,3.68,,,fee schedule,,,3.42,,,percent of total billed charges,,,,,,,,,,,,,,,3.42,,,percent of total billed charges,,,3.42,,,percent of total billed charges,,,3.42,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,3.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.68,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.58,,,percent of total billed charges,,
PHENOL 1.4  SOLN 180 ML,2500015150,CDM,637,RC,904630521,NDC,999,EAPG,,,,outpatient,facility,180,UN,3.68,3.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRINE 0.5  NASAL 15ML,2500015202,CDM,637,RC,225080547,NDC,,,,,,inpatient,facility,15,UN,4.91,4.91,0.39,4.91,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,4.91,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.45,,,percent of total billed charges,,
PHENYLEPHRINE 0.5  NASAL 15ML,2500015202,CDM,637,RC,225080547,NDC,,,,,,outpatient,facility,15,UN,4.91,4.91,0.39,618.77,,2.87,,,percent of total billed charges,,,0.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.91,,,percent of total billed charges,,,4.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.42,,,percent of total billed charges,,,,,,,,,4.91,,,percent of total billed charges,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.73,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.82,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,4.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.39,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,4.91,,,fee schedule,,,4.57,,,percent of total billed charges,,,,,,,,,,,,,,,4.57,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,4.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.45,,,percent of total billed charges,,
PHENYLEPHRINE 0.5  NASAL 15ML,2500015202,CDM,637,RC,225080547,NDC,999,EAPG,,,,outpatient,facility,15,UN,4.91,4.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYTOIN 50 MG CHEW TAB,2500015240,CDM,637,RC,6068715625,NDC,,,,,,inpatient,facility,50,UN,5.94,5.94,0.48,5.94,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.35,,,percent of total billed charges,,,,,,,,,5.94,,,percent of total billed charges,,,3.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.17,,,percent of total billed charges,,
PHENYTOIN 50 MG CHEW TAB,2500015240,CDM,637,RC,6068715625,NDC,,,,,,outpatient,facility,50,UN,5.94,5.94,0.48,618.77,,3.47,,,percent of total billed charges,,,1.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.94,,,percent of total billed charges,,,5.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.35,,,percent of total billed charges,,,,,,,,,5.94,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.56,,,percent of total billed charges,,,,,,,,,,,,,,,3.21,,,percent of total billed charges,,,3.21,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.51,,,percent of total billed charges,,,2.25,,,percent of total billed charges,,,3.08,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.2,,,percent of total billed charges,,,2.2,,,percent of total billed charges,,,5.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.48,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,,,,,,,5.94,,,fee schedule,,,5.53,,,percent of total billed charges,,,,,,,,,,,,,,,5.53,,,percent of total billed charges,,,5.53,,,percent of total billed charges,,,5.53,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,5.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.94,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.17,,,percent of total billed charges,,
PHENYTOIN 50 MG CHEW TAB,2500015240,CDM,637,RC,6068715625,NDC,999,EAPG,,,,outpatient,facility,50,UN,5.94,5.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYTOIN 100 MG CAP,2500015241,CDM,637,RC,904618761,NDC,,,,,,inpatient,facility,100,UN,2.01,2.01,0.16,2.01,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,
PHENYTOIN 100 MG CAP,2500015241,CDM,637,RC,904618761,NDC,,,,,,outpatient,facility,100,UN,2.01,2.01,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.01,,,percent of total billed charges,,,1.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.81,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,2.01,,,fee schedule,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,2.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.41,,,percent of total billed charges,,
PHENYTOIN 100 MG CAP,2500015241,CDM,637,RC,904618761,NDC,999,EAPG,,,,outpatient,facility,100,UN,2.01,2.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYTOIN 30 MG CAP,2500015242,CDM,637,RC,71374066,NDC,,,,,,inpatient,facility,30,UN,4.79,4.79,0.38,4.79,,,,,,,,,,,,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.31,,,percent of total billed charges,,,,,,,,,4.79,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,4.79,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,
PHENYTOIN 30 MG CAP,2500015242,CDM,637,RC,71374066,NDC,,,,,,outpatient,facility,30,UN,4.79,4.79,0.38,618.77,,2.8,,,percent of total billed charges,,,0.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.79,,,percent of total billed charges,,,4.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.31,,,percent of total billed charges,,,,,,,,,4.79,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,2.59,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.77,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,4.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.38,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,4.79,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,,,,,,,4.79,,,fee schedule,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,3.59,,,percent of total billed charges,,,4.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.79,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.36,,,percent of total billed charges,,
PHENYTOIN 30 MG CAP,2500015242,CDM,637,RC,71374066,NDC,999,EAPG,,,,outpatient,facility,30,UN,4.79,4.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYTOIN 100 MG/4 ML UDC,2500015245,CDM,637,RC,6668903650,NDC,,,,,,inpatient,facility,4,ML,28.51,28.51,2.28,28.51,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.66,,,percent of total billed charges,,,,,,,,,28.51,,,percent of total billed charges,,,15.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,14.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.02,,,percent of total billed charges,,
PHENYTOIN 100 MG/4 ML UDC,2500015245,CDM,637,RC,6668903650,NDC,,,,,,outpatient,facility,4,ML,28.51,28.51,2.28,618.77,,16.65,,,percent of total billed charges,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,28.51,,,percent of total billed charges,,,25.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,25.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,25.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,25.66,,,percent of total billed charges,,,,,,,,,28.51,,,percent of total billed charges,,,19.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.9,,,percent of total billed charges,,,,,,,,,,,,,,,15.4,,,percent of total billed charges,,,15.4,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.87,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.67,,,percent of total billed charges,,,10.8,,,percent of total billed charges,,,14.77,,,percent of total billed charges,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.55,,,percent of total billed charges,,,10.55,,,percent of total billed charges,,,28.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.28,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,,,,,,,28.51,,,fee schedule,,,26.52,,,percent of total billed charges,,,,,,,,,,,,,,,26.52,,,percent of total billed charges,,,26.52,,,percent of total billed charges,,,26.52,,,percent of total billed charges,,,21.38,,,percent of total billed charges,,,28.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,28.51,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.26,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.02,,,percent of total billed charges,,
PHENYTOIN 100 MG/4 ML UDC,2500015245,CDM,637,RC,6668903650,NDC,999,EAPG,,,,outpatient,facility,4,ML,28.51,28.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHYTONADIONE 5 MG TAB,2500015260,CDM,637,RC,409915801,NDC,,,,,,inpatient,facility,5,UN,221.06,221.06,17.68,221.06,,,,,,,,,,,,,,221.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.95,,,percent of total billed charges,,,,,,,,,221.06,,,percent of total billed charges,,,122.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.06,,,percent of total billed charges,,,,,,,,,,,,,,,221.06,,,percent of total billed charges,,,115.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.68,,,percent of total billed charges,,,221.06,,,percent of total billed charges,,,221.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,221.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.23,,,percent of total billed charges,,
PHYTONADIONE 5 MG TAB,2500015260,CDM,637,RC,409915801,NDC,,,,,,outpatient,facility,5,UN,221.06,221.06,17.68,618.77,,129.1,,,percent of total billed charges,,,43.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,221.06,,,percent of total billed charges,,,194.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,194.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,194.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,221.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,80.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,198.95,,,percent of total billed charges,,,,,,,,,221.06,,,percent of total billed charges,,,149.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.77,,,percent of total billed charges,,,,,,,,,,,,,,,119.37,,,percent of total billed charges,,,119.37,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,221.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,115.26,,,percent of total billed charges,,,221.06,,,percent of total billed charges,,,221.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.01,,,percent of total billed charges,,,83.74,,,percent of total billed charges,,,114.49,,,percent of total billed charges,,,,,,,,,,,,,,,44.21,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,81.79,,,percent of total billed charges,,,81.79,,,percent of total billed charges,,,221.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,221.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.68,,,percent of total billed charges,,,221.06,,,percent of total billed charges,,,221.06,,,percent of total billed charges,,,,,,,,,,,,,,,221.06,,,percent of total billed charges,,,221.06,,,percent of total billed charges,,,,,,,,,221.06,,,fee schedule,,,205.63,,,percent of total billed charges,,,,,,,,,,,,,,,205.63,,,percent of total billed charges,,,205.63,,,percent of total billed charges,,,205.63,,,percent of total billed charges,,,165.8,,,percent of total billed charges,,,221.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,221.06,,,percent of total billed charges,,,221.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,155.23,,,percent of total billed charges,,
PHYTONADIONE 5 MG TAB,2500015260,CDM,637,RC,409915801,NDC,999,EAPG,,,,outpatient,facility,5,UN,221.06,221.06,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PILOCARPINE HCL 1  OPH 15ML,2500015273,CDM,637,RC,6131420315,NDC,,,,,,inpatient,facility,15,UN,325.25,325.25,26.02,325.25,,,,,,,,,,,,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,292.73,,,percent of total billed charges,,,,,,,,,325.25,,,percent of total billed charges,,,180.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,325.25,,,percent of total billed charges,,,169.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.02,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.39,,,percent of total billed charges,,
PILOCARPINE HCL 1  OPH 15ML,2500015273,CDM,637,RC,6131420315,NDC,,,,,,outpatient,facility,15,UN,325.25,325.25,26.02,618.77,,189.95,,,percent of total billed charges,,,63.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,325.25,,,percent of total billed charges,,,286.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,286.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,286.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,119.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,292.73,,,percent of total billed charges,,,,,,,,,325.25,,,percent of total billed charges,,,220.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.79,,,percent of total billed charges,,,,,,,,,,,,,,,175.64,,,percent of total billed charges,,,175.64,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,169.59,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247.19,,,percent of total billed charges,,,123.2,,,percent of total billed charges,,,168.45,,,percent of total billed charges,,,,,,,,,,,,,,,65.05,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,120.34,,,percent of total billed charges,,,120.34,,,percent of total billed charges,,,325.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,325.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.02,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,325.25,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,,,,,,,325.25,,,fee schedule,,,302.55,,,percent of total billed charges,,,,,,,,,,,,,,,302.55,,,percent of total billed charges,,,302.55,,,percent of total billed charges,,,302.55,,,percent of total billed charges,,,243.94,,,percent of total billed charges,,,325.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,325.25,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,228.39,,,percent of total billed charges,,
PILOCARPINE HCL 1  OPH 15ML,2500015273,CDM,637,RC,6131420315,NDC,999,EAPG,,,,outpatient,facility,15,UN,325.25,325.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PILOCARPINE HCL 2  OPH 15ML,2500015275,CDM,637,RC,6131420415,NDC,,,,,,inpatient,facility,15,UN,332.67,332.67,26.61,332.67,,,,,,,,,,,,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.4,,,percent of total billed charges,,,,,,,,,332.67,,,percent of total billed charges,,,184.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,332.67,,,percent of total billed charges,,,173.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.61,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.6,,,percent of total billed charges,,
PILOCARPINE HCL 2  OPH 15ML,2500015275,CDM,637,RC,6131420415,NDC,,,,,,outpatient,facility,15,UN,332.67,332.67,26.61,618.77,,194.28,,,percent of total billed charges,,,64.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,332.67,,,percent of total billed charges,,,292.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,292.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,292.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,121.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,299.4,,,percent of total billed charges,,,,,,,,,332.67,,,percent of total billed charges,,,225.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.49,,,percent of total billed charges,,,,,,,,,,,,,,,179.64,,,percent of total billed charges,,,179.64,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.45,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.83,,,percent of total billed charges,,,126.02,,,percent of total billed charges,,,172.29,,,percent of total billed charges,,,,,,,,,,,,,,,66.53,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,123.09,,,percent of total billed charges,,,123.09,,,percent of total billed charges,,,332.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,332.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.61,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,332.67,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,,,,,,,332.67,,,fee schedule,,,309.45,,,percent of total billed charges,,,,,,,,,,,,,,,309.45,,,percent of total billed charges,,,309.45,,,percent of total billed charges,,,309.45,,,percent of total billed charges,,,249.5,,,percent of total billed charges,,,332.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,332.67,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,233.6,,,percent of total billed charges,,
PILOCARPINE HCL 2  OPH 15ML,2500015275,CDM,637,RC,6131420415,NDC,999,EAPG,,,,outpatient,facility,15,UN,332.67,332.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIOGLITAZONE HCL 15 MG TAB,2500015310,CDM,637,RC,5723721930,NDC,,,,,,inpatient,facility,15,UN,23.13,23.13,1.85,23.13,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.82,,,percent of total billed charges,,,,,,,,,23.13,,,percent of total billed charges,,,12.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,12.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.24,,,percent of total billed charges,,
PIOGLITAZONE HCL 15 MG TAB,2500015310,CDM,637,RC,5723721930,NDC,,,,,,outpatient,facility,15,UN,23.13,23.13,1.85,618.77,,13.51,,,percent of total billed charges,,,4.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,23.13,,,percent of total billed charges,,,20.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,20.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,20.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,20.82,,,percent of total billed charges,,,,,,,,,23.13,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.76,,,percent of total billed charges,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,12.49,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.06,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.58,,,percent of total billed charges,,,8.76,,,percent of total billed charges,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.56,,,percent of total billed charges,,,8.56,,,percent of total billed charges,,,23.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.85,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,,,,,,,23.13,,,fee schedule,,,21.52,,,percent of total billed charges,,,,,,,,,,,,,,,21.52,,,percent of total billed charges,,,21.52,,,percent of total billed charges,,,21.52,,,percent of total billed charges,,,17.35,,,percent of total billed charges,,,23.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,23.13,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,16.24,,,percent of total billed charges,,
PIOGLITAZONE HCL 15 MG TAB,2500015310,CDM,637,RC,5723721930,NDC,999,EAPG,,,,outpatient,facility,15,UN,23.13,23.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIROXICAM 10 MG CAP,2500015330,CDM,637,RC,93075601,NDC,,,,,,inpatient,facility,10,UN,8.58,8.58,0.69,8.58,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,,,,8.58,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,4.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,
PIROXICAM 10 MG CAP,2500015330,CDM,637,RC,93075601,NDC,,,,,,outpatient,facility,10,UN,8.58,8.58,0.69,618.77,,5.01,,,percent of total billed charges,,,1.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.58,,,percent of total billed charges,,,7.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.72,,,percent of total billed charges,,,,,,,,,8.58,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.59,,,percent of total billed charges,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,4.63,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.47,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.52,,,percent of total billed charges,,,3.25,,,percent of total billed charges,,,4.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,8.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.69,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,8.58,,,fee schedule,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,6.44,,,percent of total billed charges,,,8.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.58,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.02,,,percent of total billed charges,,
PIROXICAM 10 MG CAP,2500015330,CDM,637,RC,93075601,NDC,999,EAPG,,,,outpatient,facility,10,UN,8.58,8.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POLYETHYLENE GLYCOL 238 GM,2500015380,CDM,637,RC,5199196158,NDC,,,,,,inpatient,facility,238,UN,18.71,18.71,1.5,18.71,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.84,,,percent of total billed charges,,,,,,,,,18.71,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,9.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.14,,,percent of total billed charges,,
POLYETHYLENE GLYCOL 238 GM,2500015380,CDM,637,RC,5199196158,NDC,,,,,,outpatient,facility,238,UN,18.71,18.71,1.5,618.77,,10.93,,,percent of total billed charges,,,3.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,18.71,,,percent of total billed charges,,,16.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,16.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,16.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,16.84,,,percent of total billed charges,,,,,,,,,18.71,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.37,,,percent of total billed charges,,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.76,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,7.09,,,percent of total billed charges,,,9.69,,,percent of total billed charges,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.92,,,percent of total billed charges,,,6.92,,,percent of total billed charges,,,18.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.5,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,18.71,,,fee schedule,,,17.4,,,percent of total billed charges,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,14.03,,,percent of total billed charges,,,18.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,18.71,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,13.14,,,percent of total billed charges,,
POLYETHYLENE GLYCOL 238 GM,2500015380,CDM,637,RC,5199196158,NDC,999,EAPG,,,,outpatient,facility,238,UN,18.71,18.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POLYMYXIN B SULF INJ 500000 U,2500015391,CDM,250,RC,5515023410,NDC,,,,,,inpatient,facility,500000,UN,57.75,57.75,4.62,57.75,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.98,,,percent of total billed charges,,,,,,,,,57.75,,,percent of total billed charges,,,31.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,30.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.55,,,percent of total billed charges,,
POLYMYXIN B SULF INJ 500000 U,2500015391,CDM,250,RC,5515023410,NDC,,,,,,outpatient,facility,500000,UN,57.75,57.75,4.62,618.77,,33.73,,,percent of total billed charges,,,11.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,57.75,,,percent of total billed charges,,,50.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,50.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,50.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,21.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,51.98,,,percent of total billed charges,,,,,,,,,57.75,,,percent of total billed charges,,,39.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.11,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,21.88,,,percent of total billed charges,,,29.91,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,23.1,,,percent of total billed charges,,,23.1,,,percent of total billed charges,,,57.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,57.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.62,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,,,,,,,57.75,,,fee schedule,,,23.1,,,percent of total billed charges,,,,,,,,,,,,,,,23.1,,,percent of total billed charges,,,23.1,,,percent of total billed charges,,,23.1,,,percent of total billed charges,,,43.31,,,percent of total billed charges,,,57.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,57.75,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,40.55,,,percent of total billed charges,,
POLYMYXIN B SULF INJ 500000 U,2500015391,CDM,250,RC,5515023410,NDC,999,EAPG,,,,outpatient,facility,500000,UN,57.75,57.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POLYMIN/TRIMETHOPRIM OPH 10ML,2500015392,CDM,637,RC,6075890810,NDC,,,,,,inpatient,facility,10,UN,43.13,43.13,3.45,43.13,,,,,,,,,,,,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.82,,,percent of total billed charges,,,,,,,,,43.13,,,percent of total billed charges,,,23.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,43.13,,,percent of total billed charges,,,22.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.45,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.29,,,percent of total billed charges,,
POLYMIN/TRIMETHOPRIM OPH 10ML,2500015392,CDM,637,RC,6075890810,NDC,,,,,,outpatient,facility,10,UN,43.13,43.13,3.45,618.77,,25.19,,,percent of total billed charges,,,8.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,43.13,,,percent of total billed charges,,,37.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,37.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,37.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,15.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,38.82,,,percent of total billed charges,,,,,,,,,43.13,,,percent of total billed charges,,,29.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.12,,,percent of total billed charges,,,,,,,,,,,,,,,23.29,,,percent of total billed charges,,,23.29,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.49,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.78,,,percent of total billed charges,,,16.34,,,percent of total billed charges,,,22.34,,,percent of total billed charges,,,,,,,,,,,,,,,8.63,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,15.96,,,percent of total billed charges,,,15.96,,,percent of total billed charges,,,43.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.45,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,43.13,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,,,,,,,43.13,,,fee schedule,,,40.12,,,percent of total billed charges,,,,,,,,,,,,,,,40.12,,,percent of total billed charges,,,40.12,,,percent of total billed charges,,,40.12,,,percent of total billed charges,,,32.35,,,percent of total billed charges,,,43.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,43.13,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,30.29,,,percent of total billed charges,,
POLYMIN/TRIMETHOPRIM OPH 10ML,2500015392,CDM,637,RC,6075890810,NDC,999,EAPG,,,,outpatient,facility,10,UN,43.13,43.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CL PWD 20 MEQ PACK,2500015474,CDM,637,RC,6923816173,NDC,,,,,,inpatient,facility,20,UN,35.44,35.44,2.84,35.44,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.9,,,percent of total billed charges,,,,,,,,,35.44,,,percent of total billed charges,,,19.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,18.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.89,,,percent of total billed charges,,
POTASSIUM CL PWD 20 MEQ PACK,2500015474,CDM,637,RC,6923816173,NDC,,,,,,outpatient,facility,20,UN,35.44,35.44,2.84,618.77,,20.7,,,percent of total billed charges,,,6.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,35.44,,,percent of total billed charges,,,31.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,31.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,31.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,12.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,31.9,,,percent of total billed charges,,,,,,,,,35.44,,,percent of total billed charges,,,24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.22,,,percent of total billed charges,,,,,,,,,,,,,,,19.14,,,percent of total billed charges,,,19.14,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.93,,,percent of total billed charges,,,13.42,,,percent of total billed charges,,,18.35,,,percent of total billed charges,,,,,,,,,,,,,,,7.09,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,13.11,,,percent of total billed charges,,,13.11,,,percent of total billed charges,,,35.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.84,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,,,,,,,35.44,,,fee schedule,,,32.97,,,percent of total billed charges,,,,,,,,,,,,,,,32.97,,,percent of total billed charges,,,32.97,,,percent of total billed charges,,,32.97,,,percent of total billed charges,,,26.58,,,percent of total billed charges,,,35.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,35.44,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,24.89,,,percent of total billed charges,,
POTASSIUM CL PWD 20 MEQ PACK,2500015474,CDM,637,RC,6923816173,NDC,999,EAPG,,,,outpatient,facility,20,UN,35.44,35.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CITRATE 5 MEQ TAB,2500015480,CDM,637,RC,4254340601,NDC,,,,,,inpatient,facility,5,UN,5.77,5.77,0.46,5.77,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.19,,,percent of total billed charges,,,,,,,,,5.77,,,percent of total billed charges,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.05,,,percent of total billed charges,,
POTASSIUM CITRATE 5 MEQ TAB,2500015480,CDM,637,RC,4254340601,NDC,,,,,,outpatient,facility,5,UN,5.77,5.77,0.46,618.77,,3.37,,,percent of total billed charges,,,1.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.77,,,percent of total billed charges,,,5.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.19,,,percent of total billed charges,,,,,,,,,5.77,,,percent of total billed charges,,,3.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.43,,,percent of total billed charges,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,3.12,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.39,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.13,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,5.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,5.77,,,fee schedule,,,5.37,,,percent of total billed charges,,,,,,,,,,,,,,,5.37,,,percent of total billed charges,,,5.37,,,percent of total billed charges,,,5.37,,,percent of total billed charges,,,4.33,,,percent of total billed charges,,,5.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.05,,,percent of total billed charges,,
POTASSIUM CITRATE 5 MEQ TAB,2500015480,CDM,637,RC,4254340601,NDC,999,EAPG,,,,outpatient,facility,5,UN,5.77,5.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM/SOD PHOS PWD PK,2500015512,CDM,637,RC,6025800601,NDC,,,,,,inpatient,facility,1.5,UN,1.81,1.81,0.14,1.81,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,,,,,,,1.81,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,
POTASSIUM/SOD PHOS PWD PK,2500015512,CDM,637,RC,6025800601,NDC,,,,,,outpatient,facility,1.5,UN,1.81,1.81,0.14,618.77,,1.06,,,percent of total billed charges,,,0.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.81,,,percent of total billed charges,,,1.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.63,,,percent of total billed charges,,,,,,,,,1.81,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.67,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,1.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.14,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,1.81,,,fee schedule,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,1.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.27,,,percent of total billed charges,,
POTASSIUM/SOD PHOS PWD PK,2500015512,CDM,637,RC,6025800601,NDC,999,EAPG,,,,outpatient,facility,1.5,UN,1.81,1.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM PHOS 3MM/ML 5ML INJ,2500015525,CDM,250,RC,6521905229,NDC,,,,,,inpatient,facility,5,UN,79.13,79.13,6.33,79.13,,,,,,,,,,,,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.22,,,percent of total billed charges,,,,,,,,,79.13,,,percent of total billed charges,,,43.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,79.13,,,percent of total billed charges,,,41.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.57,,,percent of total billed charges,,
POTASSIUM PHOS 3MM/ML 5ML INJ,2500015525,CDM,250,RC,6521905229,NDC,,,,,,outpatient,facility,5,UN,79.13,79.13,6.33,618.77,,46.21,,,percent of total billed charges,,,15.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,79.13,,,percent of total billed charges,,,69.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,69.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,69.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,28.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,71.22,,,percent of total billed charges,,,,,,,,,79.13,,,percent of total billed charges,,,53.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.26,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.14,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,40.98,,,percent of total billed charges,,,,,,,,,,,,,,,15.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,31.65,,,percent of total billed charges,,,31.65,,,percent of total billed charges,,,79.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,79.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.33,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,79.13,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,,,,,,,79.13,,,fee schedule,,,31.65,,,percent of total billed charges,,,,,,,,,,,,,,,31.65,,,percent of total billed charges,,,31.65,,,percent of total billed charges,,,31.65,,,percent of total billed charges,,,59.35,,,percent of total billed charges,,,79.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,79.13,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,55.57,,,percent of total billed charges,,
POTASSIUM PHOS 3MM/ML 5ML INJ,2500015525,CDM,250,RC,6521905229,NDC,999,EAPG,,,,outpatient,facility,5,UN,79.13,79.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRAMIPEXOLE 0.125 MG TAB,2500015560,CDM,637,RC,1366809190,NDC,,,,,,inpatient,facility,0.125,UN,9.73,9.73,0.78,9.73,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.76,,,percent of total billed charges,,,,,,,,,9.73,,,percent of total billed charges,,,5.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,
PRAMIPEXOLE 0.125 MG TAB,2500015560,CDM,637,RC,1366809190,NDC,,,,,,outpatient,facility,0.125,UN,9.73,9.73,0.78,618.77,,5.68,,,percent of total billed charges,,,1.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.73,,,percent of total billed charges,,,8.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,8.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,8.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.76,,,percent of total billed charges,,,,,,,,,9.73,,,percent of total billed charges,,,6.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,percent of total billed charges,,,,,,,,,,,,,,,5.25,,,percent of total billed charges,,,5.25,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,3.69,,,percent of total billed charges,,,5.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.6,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,9.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.78,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,9.73,,,fee schedule,,,9.05,,,percent of total billed charges,,,,,,,,,,,,,,,9.05,,,percent of total billed charges,,,9.05,,,percent of total billed charges,,,9.05,,,percent of total billed charges,,,7.3,,,percent of total billed charges,,,9.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.83,,,percent of total billed charges,,
PRAMIPEXOLE 0.125 MG TAB,2500015560,CDM,637,RC,1366809190,NDC,999,EAPG,,,,outpatient,facility,0.125,UN,9.73,9.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRAMIPEXOLE 0.5 MG TAB,2500015563,CDM,637,RC,1366809390,NDC,,,,,,inpatient,facility,0.5,UN,9.73,9.73,0.78,9.73,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.76,,,percent of total billed charges,,,,,,,,,9.73,,,percent of total billed charges,,,5.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,
PRAMIPEXOLE 0.5 MG TAB,2500015563,CDM,637,RC,1366809390,NDC,,,,,,outpatient,facility,0.5,UN,9.73,9.73,0.78,618.77,,5.68,,,percent of total billed charges,,,1.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.73,,,percent of total billed charges,,,8.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,8.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,8.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.76,,,percent of total billed charges,,,,,,,,,9.73,,,percent of total billed charges,,,6.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,percent of total billed charges,,,,,,,,,,,,,,,5.25,,,percent of total billed charges,,,5.25,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,3.69,,,percent of total billed charges,,,5.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.6,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,9.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.78,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,9.73,,,fee schedule,,,9.05,,,percent of total billed charges,,,,,,,,,,,,,,,9.05,,,percent of total billed charges,,,9.05,,,percent of total billed charges,,,9.05,,,percent of total billed charges,,,7.3,,,percent of total billed charges,,,9.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.83,,,percent of total billed charges,,
PRAMIPEXOLE 0.5 MG TAB,2500015563,CDM,637,RC,1366809390,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,9.73,9.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRAVASTATIN SOD 10 MG TAB,2500015580,CDM,637,RC,904589161,NDC,,,,,,inpatient,facility,10,UN,1.29,1.29,0.1,1.29,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,
PRAVASTATIN SOD 10 MG TAB,2500015580,CDM,637,RC,904589161,NDC,,,,,,outpatient,facility,10,UN,1.29,1.29,0.1,618.77,,0.75,,,percent of total billed charges,,,0.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.29,,,percent of total billed charges,,,1.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.16,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.48,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,1.29,,,fee schedule,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,1.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.91,,,percent of total billed charges,,
PRAVASTATIN SOD 10 MG TAB,2500015580,CDM,637,RC,904589161,NDC,999,EAPG,,,,outpatient,facility,10,UN,1.29,1.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRAVASTATIN SOD 20 MG TAB,2500015582,CDM,637,RC,904589261,NDC,,,,,,inpatient,facility,20,UN,1.84,1.84,0.15,1.84,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,1.84,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,
PRAVASTATIN SOD 20 MG TAB,2500015582,CDM,637,RC,904589261,NDC,,,,,,outpatient,facility,20,UN,1.84,1.84,0.15,618.77,,1.07,,,percent of total billed charges,,,0.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.84,,,percent of total billed charges,,,1.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.66,,,percent of total billed charges,,,,,,,,,1.84,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,1.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,1.84,,,fee schedule,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,1.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.29,,,percent of total billed charges,,
PRAVASTATIN SOD 20 MG TAB,2500015582,CDM,637,RC,904589261,NDC,999,EAPG,,,,outpatient,facility,20,UN,1.84,1.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRAZOSIN HCL 1 MG CAP,2500015600,CDM,637,RC,5976253101,NDC,,,,,,inpatient,facility,1,UN,2.97,2.97,0.24,2.97,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.09,,,percent of total billed charges,,
PRAZOSIN HCL 1 MG CAP,2500015600,CDM,637,RC,5976253101,NDC,,,,,,outpatient,facility,1,UN,2.97,2.97,0.24,618.77,,1.73,,,percent of total billed charges,,,0.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.97,,,percent of total billed charges,,,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.67,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,fee schedule,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.09,,,percent of total billed charges,,
PRAZOSIN HCL 1 MG CAP,2500015600,CDM,637,RC,5976253101,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.97,2.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRAZOSIN HCL 5 MG CAP,2500015605,CDM,637,RC,5976253501,NDC,,,,,,inpatient,facility,5,UN,7.19,7.19,0.58,7.19,,,,,,,,,,,,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.47,,,percent of total billed charges,,,,,,,,,7.19,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,7.19,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.05,,,percent of total billed charges,,
PRAZOSIN HCL 5 MG CAP,2500015605,CDM,637,RC,5976253501,NDC,,,,,,outpatient,facility,5,UN,7.19,7.19,0.58,618.77,,4.2,,,percent of total billed charges,,,1.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.19,,,percent of total billed charges,,,6.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.47,,,percent of total billed charges,,,,,,,,,7.19,,,percent of total billed charges,,,4.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.52,,,percent of total billed charges,,,,,,,,,,,,,,,3.88,,,percent of total billed charges,,,3.88,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,3.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.66,,,percent of total billed charges,,,2.66,,,percent of total billed charges,,,7.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.58,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,7.19,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,,,,,,,7.19,,,fee schedule,,,6.69,,,percent of total billed charges,,,,,,,,,,,,,,,6.69,,,percent of total billed charges,,,6.69,,,percent of total billed charges,,,6.69,,,percent of total billed charges,,,5.39,,,percent of total billed charges,,,7.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.19,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.05,,,percent of total billed charges,,
PRAZOSIN HCL 5 MG CAP,2500015605,CDM,637,RC,5976253501,NDC,999,EAPG,,,,outpatient,facility,5,UN,7.19,7.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREDNISOLONE AC 1  OP 5 ML,2500015617,CDM,637,RC,6131463705,NDC,,,,,,inpatient,facility,5,UN,182.56,182.56,14.6,182.56,,,,,,,,,,,,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.3,,,percent of total billed charges,,,,,,,,,182.56,,,percent of total billed charges,,,101.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,182.56,,,percent of total billed charges,,,95.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.6,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.19,,,percent of total billed charges,,
PREDNISOLONE AC 1  OP 5 ML,2500015617,CDM,637,RC,6131463705,NDC,,,,,,outpatient,facility,5,UN,182.56,182.56,14.6,618.77,,106.62,,,percent of total billed charges,,,35.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,182.56,,,percent of total billed charges,,,160.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,160.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,160.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,66.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,164.3,,,percent of total billed charges,,,,,,,,,182.56,,,percent of total billed charges,,,123.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.21,,,percent of total billed charges,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,98.58,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.19,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.75,,,percent of total billed charges,,,69.15,,,percent of total billed charges,,,94.55,,,percent of total billed charges,,,,,,,,,,,,,,,36.51,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,67.55,,,percent of total billed charges,,,67.55,,,percent of total billed charges,,,182.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,182.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.6,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,182.56,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,,,,,,,182.56,,,fee schedule,,,169.82,,,percent of total billed charges,,,,,,,,,,,,,,,169.82,,,percent of total billed charges,,,169.82,,,percent of total billed charges,,,169.82,,,percent of total billed charges,,,136.92,,,percent of total billed charges,,,182.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,182.56,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,128.19,,,percent of total billed charges,,
PREDNISOLONE AC 1  OP 5 ML,2500015617,CDM,637,RC,6131463705,NDC,999,EAPG,,,,outpatient,facility,5,UN,182.56,182.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREDNISONE 1 MG TAB,2500015640,CDM,637,RC,J7512,HCPCS,54873925,NDC,,,,inpatient,facility,1,UN,0.92,0.92,0.07,0.92,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,
PREDNISONE 1 MG TAB,2500015640,CDM,637,RC,J7512,HCPCS,54873925,NDC,,,,outpatient,facility,1,UN,0.92,0.92,0.01,618.77,,0.54,,,percent of total billed charges,,,0.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.83,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,0.92,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.01,,,fee schedule,,,0.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.65,,,percent of total billed charges,,
PREDNISONE 1 MG TAB,2500015640,CDM,637,RC,J7512,HCPCS,54873925,NDC,496,EAPG,,outpatient,facility,1,UN,0.92,0.92,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREDNISONE 10 MG TAB,2500015641,CDM,637,RC,J7512,HCPCS,904692361,NDC,,,,inpatient,facility,10,UN,0.49,0.49,0.04,0.49,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,
PREDNISONE 10 MG TAB,2500015641,CDM,637,RC,J7512,HCPCS,904692361,NDC,,,,outpatient,facility,10,UN,0.49,0.49,0.01,618.77,,0.29,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.49,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.44,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,0.49,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.01,,,fee schedule,,,0.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.34,,,percent of total billed charges,,
PREDNISONE 10 MG TAB,2500015641,CDM,637,RC,J7512,HCPCS,904692361,NDC,496,EAPG,,outpatient,facility,10,UN,0.49,0.49,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREDNISONE 20 MG TAB,2500015642,CDM,637,RC,J7512,HCPCS,54001820,NDC,,,,inpatient,facility,20,UN,0.92,0.92,0.07,0.92,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,
PREDNISONE 20 MG TAB,2500015642,CDM,637,RC,J7512,HCPCS,54001820,NDC,,,,outpatient,facility,20,UN,0.92,0.92,0.01,618.77,,0.54,,,percent of total billed charges,,,0.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.83,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,0.92,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.01,,,fee schedule,,,0.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.65,,,percent of total billed charges,,
PREDNISONE 20 MG TAB,2500015642,CDM,637,RC,J7512,HCPCS,54001820,NDC,496,EAPG,,outpatient,facility,20,UN,0.92,0.92,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREDNISONE 5 MG TAB,2500015643,CDM,637,RC,J7512,HCPCS,6068712201,NDC,,,,inpatient,facility,5,UN,0.66,0.66,0.05,0.66,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,
PREDNISONE 5 MG TAB,2500015643,CDM,637,RC,J7512,HCPCS,6068712201,NDC,,,,outpatient,facility,5,UN,0.66,0.66,0.01,618.77,,0.39,,,percent of total billed charges,,,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.66,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.59,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,0.66,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.01,,,fee schedule,,,0.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.46,,,percent of total billed charges,,
PREDNISONE 5 MG TAB,2500015643,CDM,637,RC,J7512,HCPCS,6068712201,NDC,496,EAPG,,outpatient,facility,5,UN,0.66,0.66,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRENATAL VITAMIN TAB,2500015660,CDM,637,RC,904531360,NDC,,,,,,inpatient,facility,1,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
PRENATAL VITAMIN TAB,2500015660,CDM,637,RC,904531360,NDC,,,,,,outpatient,facility,1,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
PRENATAL VITAMIN TAB,2500015660,CDM,637,RC,904531360,NDC,999,EAPG,,,,outpatient,facility,1,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRIMIDONE 250 MG TAB,2500015700,CDM,637,RC,5374654501,NDC,,,,,,inpatient,facility,250,UN,3.3,3.3,0.26,3.3,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,3.3,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,
PRIMIDONE 250 MG TAB,2500015700,CDM,637,RC,5374654501,NDC,,,,,,outpatient,facility,250,UN,3.3,3.3,0.26,618.77,,1.93,,,percent of total billed charges,,,0.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.3,,,percent of total billed charges,,,2.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.97,,,percent of total billed charges,,,,,,,,,3.3,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,3.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,3.3,,,fee schedule,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,3.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.32,,,percent of total billed charges,,
PRIMIDONE 250 MG TAB,2500015700,CDM,637,RC,5374654501,NDC,999,EAPG,,,,outpatient,facility,250,UN,3.3,3.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRIMIDONE 50 MG TAB,2500015701,CDM,637,RC,6808420201,NDC,,,,,,inpatient,facility,50,UN,3.23,3.23,0.26,3.23,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.27,,,percent of total billed charges,,
PRIMIDONE 50 MG TAB,2500015701,CDM,637,RC,6808420201,NDC,,,,,,outpatient,facility,50,UN,3.23,3.23,0.26,618.77,,1.89,,,percent of total billed charges,,,0.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.23,,,percent of total billed charges,,,2.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.91,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,3.23,,,fee schedule,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,3.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.27,,,percent of total billed charges,,
PRIMIDONE 50 MG TAB,2500015701,CDM,637,RC,6808420201,NDC,999,EAPG,,,,outpatient,facility,50,UN,3.23,3.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROBENECID 500 MG TAB,2500015710,CDM,637,RC,591534701,NDC,,,,,,inpatient,facility,500,UN,3.23,3.23,0.26,3.23,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.27,,,percent of total billed charges,,
PROBENECID 500 MG TAB,2500015710,CDM,637,RC,591534701,NDC,,,,,,outpatient,facility,500,UN,3.23,3.23,0.26,618.77,,1.89,,,percent of total billed charges,,,0.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.23,,,percent of total billed charges,,,2.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.91,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,3.23,,,fee schedule,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,3.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.27,,,percent of total billed charges,,
PROBENECID 500 MG TAB,2500015710,CDM,637,RC,591534701,NDC,999,EAPG,,,,outpatient,facility,500,UN,3.23,3.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROCHLORPERAZINE 25 MG SUPP,2500015761,CDM,637,RC,J8498,HCPCS,713013512,NDC,,,,inpatient,facility,25,UN,40.46,40.46,3.24,40.46,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.41,,,percent of total billed charges,,,,,,,,,40.46,,,percent of total billed charges,,,22.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,21.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.24,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.41,,,percent of total billed charges,,
PROCHLORPERAZINE 25 MG SUPP,2500015761,CDM,637,RC,J8498,HCPCS,713013512,NDC,,,,outpatient,facility,25,UN,40.46,40.46,2.2,618.77,,23.63,,,percent of total billed charges,,,7.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,40.46,,,percent of total billed charges,,,35.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,35.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,35.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,14.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,36.41,,,percent of total billed charges,,,,,,,,,40.46,,,percent of total billed charges,,,27.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.07,,,percent of total billed charges,,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.1,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.75,,,percent of total billed charges,,,15.33,,,percent of total billed charges,,,20.95,,,percent of total billed charges,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.13,,,fee schedule,,,3.18,,,fee schedule,,,40.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.24,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,,,,,,,40.46,,,fee schedule,,,3.39,,,fee schedule,,,,,,,,,,,,,,,2.99,,,fee schedule,,,3.98,,,fee schedule,,,2.2,,,fee schedule,,,30.34,,,percent of total billed charges,,,40.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,40.46,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,28.41,,,percent of total billed charges,,
PROCHLORPERAZINE 25 MG SUPP,2500015761,CDM,637,RC,J8498,HCPCS,713013512,NDC,999,EAPG,,outpatient,facility,25,UN,40.46,40.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROMETHAZINE 12.5 MG SUPP,2500015790,CDM,637,RC,713053612,NDC,,,,,,inpatient,facility,12.5,UN,58.44,58.44,4.68,58.44,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.6,,,percent of total billed charges,,,,,,,,,58.44,,,percent of total billed charges,,,32.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,30.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.04,,,percent of total billed charges,,
PROMETHAZINE 12.5 MG SUPP,2500015790,CDM,637,RC,713053612,NDC,,,,,,outpatient,facility,12.5,UN,58.44,58.44,4.68,618.77,,34.13,,,percent of total billed charges,,,11.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,58.44,,,percent of total billed charges,,,51.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,51.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,51.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,21.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,52.6,,,percent of total billed charges,,,,,,,,,58.44,,,percent of total billed charges,,,39.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.88,,,percent of total billed charges,,,,,,,,,,,,,,,31.56,,,percent of total billed charges,,,31.56,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.47,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.41,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,30.27,,,percent of total billed charges,,,,,,,,,,,,,,,11.69,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,21.62,,,percent of total billed charges,,,21.62,,,percent of total billed charges,,,58.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,58.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.68,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,,,,,,,58.44,,,fee schedule,,,54.36,,,percent of total billed charges,,,,,,,,,,,,,,,54.36,,,percent of total billed charges,,,54.36,,,percent of total billed charges,,,54.36,,,percent of total billed charges,,,43.83,,,percent of total billed charges,,,58.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,58.44,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,41.04,,,percent of total billed charges,,
PROMETHAZINE 12.5 MG SUPP,2500015790,CDM,637,RC,713053612,NDC,999,EAPG,,,,outpatient,facility,12.5,UN,58.44,58.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROMETHAZINE 25 MG SUPP,2500015791,CDM,637,RC,713052612,NDC,,,,,,inpatient,facility,25,UN,58.44,58.44,4.68,58.44,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.6,,,percent of total billed charges,,,,,,,,,58.44,,,percent of total billed charges,,,32.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,30.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.04,,,percent of total billed charges,,
PROMETHAZINE 25 MG SUPP,2500015791,CDM,637,RC,713052612,NDC,,,,,,outpatient,facility,25,UN,58.44,58.44,4.68,618.77,,34.13,,,percent of total billed charges,,,11.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,58.44,,,percent of total billed charges,,,51.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,51.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,51.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,21.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,52.6,,,percent of total billed charges,,,,,,,,,58.44,,,percent of total billed charges,,,39.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.88,,,percent of total billed charges,,,,,,,,,,,,,,,31.56,,,percent of total billed charges,,,31.56,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.47,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.41,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,30.27,,,percent of total billed charges,,,,,,,,,,,,,,,11.69,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,21.62,,,percent of total billed charges,,,21.62,,,percent of total billed charges,,,58.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,58.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.68,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,,,,,,,58.44,,,fee schedule,,,54.36,,,percent of total billed charges,,,,,,,,,,,,,,,54.36,,,percent of total billed charges,,,54.36,,,percent of total billed charges,,,54.36,,,percent of total billed charges,,,43.83,,,percent of total billed charges,,,58.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,58.44,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,41.04,,,percent of total billed charges,,
PROMETHAZINE 25 MG SUPP,2500015791,CDM,637,RC,713052612,NDC,999,EAPG,,,,outpatient,facility,25,UN,58.44,58.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROMETHAZINE 25 MG TAB,2500015792,CDM,637,RC,Q0169,HCPCS,904646161,NDC,,,,inpatient,facility,25,UN,0.4,0.4,0.03,0.4,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,,,,,,,0.4,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,
PROMETHAZINE 25 MG TAB,2500015792,CDM,637,RC,Q0169,HCPCS,904646161,NDC,,,,outpatient,facility,25,UN,0.4,0.4,0.03,618.77,,0.23,,,percent of total billed charges,,,0.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.4,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.36,,,percent of total billed charges,,,,,,,,,0.4,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,0.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,0.4,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.4,,,fee schedule,,,0.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.28,,,percent of total billed charges,,
PROMETHAZINE 25 MG TAB,2500015792,CDM,637,RC,Q0169,HCPCS,904646161,NDC,999,EAPG,,outpatient,facility,25,UN,0.4,0.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPAFENONE HCL 150 MG TAB,2500015800,CDM,637,RC,5965125601,NDC,,,,,,inpatient,facility,150,UN,5.41,5.41,0.43,5.41,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.87,,,percent of total billed charges,,,,,,,,,5.41,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,2.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,
PROPAFENONE HCL 150 MG TAB,2500015800,CDM,637,RC,5965125601,NDC,,,,,,outpatient,facility,150,UN,5.41,5.41,0.43,618.77,,3.16,,,percent of total billed charges,,,1.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.41,,,percent of total billed charges,,,4.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.87,,,percent of total billed charges,,,,,,,,,5.41,,,percent of total billed charges,,,3.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.15,,,percent of total billed charges,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.82,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.11,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,5.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.43,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,5.41,,,fee schedule,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,5.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.8,,,percent of total billed charges,,
PROPAFENONE HCL 150 MG TAB,2500015800,CDM,637,RC,5965125601,NDC,999,EAPG,,,,outpatient,facility,150,UN,5.41,5.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPOFOL IV 10MG/ML 100 ML INJ,2500015830,CDM,636,RC,J2704,HCPCS,6332326965,NDC,,,,inpatient,facility,100,ML,99,99,7.92,99,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,,,,,,,99,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,51.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.52,,,percent of total billed charges,,
PROPOFOL IV 10MG/ML 100 ML INJ,2500015830,CDM,636,RC,J2704,HCPCS,6332326965,NDC,,,,outpatient,facility,100,ML,99,99,0.09,618.77,,57.82,,,percent of total billed charges,,,19.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,99,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,36.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,89.1,,,percent of total billed charges,,,,,,,,,99,,,percent of total billed charges,,,67.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.62,,,percent of total billed charges,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.24,,,percent of total billed charges,,,37.5,,,percent of total billed charges,,,51.27,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.92,,,percent of total billed charges,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,99,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,69.52,,,percent of total billed charges,,
PROPOFOL IV 10MG/ML 100 ML INJ,2500015830,CDM,636,RC,J2704,HCPCS,6332326965,NDC,496,EAPG,,outpatient,facility,100,ML,99,99,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPOFOL IV 10 MG/ML 50 ML INJ,2500015833,CDM,636,RC,J2704,HCPCS,409469933,NDC,,,,inpatient,facility,50,ML,35.64,35.64,2.85,35.64,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.08,,,percent of total billed charges,,,,,,,,,35.64,,,percent of total billed charges,,,19.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,18.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.03,,,percent of total billed charges,,
PROPOFOL IV 10 MG/ML 50 ML INJ,2500015833,CDM,636,RC,J2704,HCPCS,409469933,NDC,,,,outpatient,facility,50,ML,35.64,35.64,0.09,618.77,,20.81,,,percent of total billed charges,,,6.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,35.64,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,13.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,32.08,,,percent of total billed charges,,,,,,,,,35.64,,,percent of total billed charges,,,24.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.58,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,13.5,,,percent of total billed charges,,,18.46,,,percent of total billed charges,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,35.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.85,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,35.64,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,35.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,25.03,,,percent of total billed charges,,
PROPOFOL IV 10 MG/ML 50 ML INJ,2500015833,CDM,636,RC,J2704,HCPCS,409469933,NDC,496,EAPG,,outpatient,facility,50,ML,35.64,35.64,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPRANOLOL HCL 10 MG TAB,2500015850,CDM,637,RC,904655061,NDC,,,,,,inpatient,facility,10,UN,0.76,0.76,0.06,0.76,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,
PROPRANOLOL HCL 10 MG TAB,2500015850,CDM,637,RC,904655061,NDC,,,,,,outpatient,facility,10,UN,0.76,0.76,0.06,618.77,,0.44,,,percent of total billed charges,,,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.76,,,percent of total billed charges,,,0.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.68,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.28,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,0.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,0.76,,,fee schedule,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,0.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.53,,,percent of total billed charges,,
PROPRANOLOL HCL 10 MG TAB,2500015850,CDM,637,RC,904655061,NDC,999,EAPG,,,,outpatient,facility,10,UN,0.76,0.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPRANOLOL HCL 40 MG TAB,2500015852,CDM,637,RC,5026870215,NDC,,,,,,inpatient,facility,40,UN,2.14,2.14,0.17,2.14,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,,,,,2.14,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,
PROPRANOLOL HCL 40 MG TAB,2500015852,CDM,637,RC,5026870215,NDC,,,,,,outpatient,facility,40,UN,2.14,2.14,0.17,618.77,,1.25,,,percent of total billed charges,,,0.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.14,,,percent of total billed charges,,,1.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.93,,,percent of total billed charges,,,,,,,,,2.14,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,2.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,2.14,,,fee schedule,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,2.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.5,,,percent of total billed charges,,
PROPRANOLOL HCL 40 MG TAB,2500015852,CDM,637,RC,5026870215,NDC,999,EAPG,,,,outpatient,facility,40,UN,2.14,2.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPRANOLOL LA 60 MG CAP,2500015857,CDM,637,RC,5199181701,NDC,,,,,,inpatient,facility,60,UN,6.8,6.8,0.54,6.8,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,,,,,,,6.8,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,3.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,
PROPRANOLOL LA 60 MG CAP,2500015857,CDM,637,RC,5199181701,NDC,,,,,,outpatient,facility,60,UN,6.8,6.8,0.54,618.77,,3.97,,,percent of total billed charges,,,1.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.8,,,percent of total billed charges,,,5.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.12,,,percent of total billed charges,,,,,,,,,6.8,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,3.67,,,percent of total billed charges,,,3.67,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.55,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.52,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,6.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.54,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,6.8,,,fee schedule,,,6.33,,,percent of total billed charges,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,5.1,,,percent of total billed charges,,,6.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.8,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.77,,,percent of total billed charges,,
PROPRANOLOL LA 60 MG CAP,2500015857,CDM,637,RC,5199181701,NDC,999,EAPG,,,,outpatient,facility,60,UN,6.8,6.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPRANOLOL LA 80 MG CAP,2500015858,CDM,637,RC,5199181801,NDC,,,,,,inpatient,facility,80,UN,7.95,7.95,0.64,7.95,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,7.95,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.58,,,percent of total billed charges,,
PROPRANOLOL LA 80 MG CAP,2500015858,CDM,637,RC,5199181801,NDC,,,,,,outpatient,facility,80,UN,7.95,7.95,0.64,618.77,,4.64,,,percent of total billed charges,,,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.95,,,percent of total billed charges,,,7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.16,,,percent of total billed charges,,,,,,,,,7.95,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.11,,,percent of total billed charges,,,,,,,,,,,,,,,4.29,,,percent of total billed charges,,,4.29,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.15,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.04,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.94,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,7.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.64,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,7.95,,,fee schedule,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,7.4,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,7.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.58,,,percent of total billed charges,,
PROPRANOLOL LA 80 MG CAP,2500015858,CDM,637,RC,5199181801,NDC,999,EAPG,,,,outpatient,facility,80,UN,7.95,7.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPYLTHIOURACIL 50 MG TAB,2500015860,CDM,637,RC,480924201,NDC,,,,,,inpatient,facility,50,UN,2.97,2.97,0.24,2.97,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.09,,,percent of total billed charges,,
PROPYLTHIOURACIL 50 MG TAB,2500015860,CDM,637,RC,480924201,NDC,,,,,,outpatient,facility,50,UN,2.97,2.97,0.24,618.77,,1.73,,,percent of total billed charges,,,0.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.97,,,percent of total billed charges,,,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.67,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,fee schedule,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.09,,,percent of total billed charges,,
PROPYLTHIOURACIL 50 MG TAB,2500015860,CDM,637,RC,480924201,NDC,999,EAPG,,,,outpatient,facility,50,UN,2.97,2.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PSEUDOEPHEDRINE 30 MG TAB,2500015902,CDM,637,RC,904505359,NDC,,,,,,inpatient,facility,30,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
PSEUDOEPHEDRINE 30 MG TAB,2500015902,CDM,637,RC,904505359,NDC,,,,,,outpatient,facility,30,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
PSEUDOEPHEDRINE 30 MG TAB,2500015902,CDM,637,RC,904505359,NDC,999,EAPG,,,,outpatient,facility,30,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PSYLLIUM 5.85 GM PACK,2500015910,CDM,637,RC,5192715520,NDC,,,,,,inpatient,facility,1,UN,1.83,1.83,0.15,1.83,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,1.83,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,
PSYLLIUM 5.85 GM PACK,2500015910,CDM,637,RC,5192715520,NDC,,,,,,outpatient,facility,1,UN,1.83,1.83,0.15,618.77,,1.07,,,percent of total billed charges,,,0.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.83,,,percent of total billed charges,,,1.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.65,,,percent of total billed charges,,,,,,,,,1.83,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,1.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,1.83,,,fee schedule,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,1.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.83,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.29,,,percent of total billed charges,,
PSYLLIUM 5.85 GM PACK,2500015910,CDM,637,RC,5192715520,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.83,1.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PYRIDOSTIGMINE 60 MG TAB,2500015961,CDM,637,RC,904662261,NDC,,,,,,inpatient,facility,60,UN,4.42,4.42,0.35,4.42,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.98,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,
PYRIDOSTIGMINE 60 MG TAB,2500015961,CDM,637,RC,904662261,NDC,,,,,,outpatient,facility,60,UN,4.42,4.42,0.35,618.77,,2.58,,,percent of total billed charges,,,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.42,,,percent of total billed charges,,,3.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.98,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.64,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,4.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.35,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,4.42,,,fee schedule,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,4.11,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,4.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.1,,,percent of total billed charges,,
PYRIDOSTIGMINE 60 MG TAB,2500015961,CDM,637,RC,904662261,NDC,999,EAPG,,,,outpatient,facility,60,UN,4.42,4.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PYRIDOXINE 50 MG TAB,2500015972,CDM,637,RC,7733394010,NDC,,,,,,inpatient,facility,50,UN,1.88,1.88,0.15,1.88,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,
PYRIDOXINE 50 MG TAB,2500015972,CDM,637,RC,7733394010,NDC,,,,,,outpatient,facility,50,UN,1.88,1.88,0.15,618.77,,1.1,,,percent of total billed charges,,,0.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.88,,,percent of total billed charges,,,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.69,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.7,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,1.88,,,fee schedule,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.32,,,percent of total billed charges,,
PYRIDOXINE 50 MG TAB,2500015972,CDM,637,RC,7733394010,NDC,999,EAPG,,,,outpatient,facility,50,UN,1.88,1.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PYRIDOXINE 100 MG INJ,2500015973,CDM,636,RC,J3415,HCPCS,6332318001,NDC,,,,inpatient,facility,1,UN,54.68,54.68,4.37,54.68,,,,,,,,,,,,,,54.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.21,,,percent of total billed charges,,,,,,,,,54.68,,,percent of total billed charges,,,30.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.68,,,percent of total billed charges,,,,,,,,,,,,,,,54.68,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,,54.68,,,percent of total billed charges,,,54.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.4,,,percent of total billed charges,,
PYRIDOXINE 100 MG INJ,2500015973,CDM,636,RC,J3415,HCPCS,6332318001,NDC,,,,outpatient,facility,1,UN,54.68,54.68,4.37,618.77,,31.93,,,percent of total billed charges,,,10.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,54.68,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,54.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,20.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,49.21,,,percent of total billed charges,,,,,,,,,54.68,,,percent of total billed charges,,,37.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,54.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,54.68,,,percent of total billed charges,,,54.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.56,,,percent of total billed charges,,,20.71,,,percent of total billed charges,,,28.32,,,percent of total billed charges,,,,,,,,,,,,,,,10.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,54.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,54.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.37,,,percent of total billed charges,,,54.68,,,percent of total billed charges,,,54.68,,,percent of total billed charges,,,,,,,,,,,,,,,54.68,,,percent of total billed charges,,,54.68,,,percent of total billed charges,,,,,,,,,54.68,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,10.47,,,fee schedule,,,54.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,54.68,,,percent of total billed charges,,,54.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,38.4,,,percent of total billed charges,,
PYRIDOXINE 100 MG INJ,2500015973,CDM,636,RC,J3415,HCPCS,6332318001,NDC,999,EAPG,,outpatient,facility,1,UN,54.68,54.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
QUETIAPINE 100 MG TAB,2500015990,CDM,637,RC,904664061,NDC,,,,,,inpatient,facility,100,UN,1.55,1.55,0.12,1.55,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,
QUETIAPINE 100 MG TAB,2500015990,CDM,637,RC,904664061,NDC,,,,,,outpatient,facility,100,UN,1.55,1.55,0.12,618.77,,0.91,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.55,,,percent of total billed charges,,,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.4,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.57,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,1.55,,,fee schedule,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.09,,,percent of total billed charges,,
QUETIAPINE 100 MG TAB,2500015990,CDM,637,RC,904664061,NDC,999,EAPG,,,,outpatient,facility,100,UN,1.55,1.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
QUETIAPINE 25 MG TAB,2500015991,CDM,637,RC,904663861,NDC,,,,,,inpatient,facility,25,UN,0.95,0.95,0.08,0.95,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,
QUETIAPINE 25 MG TAB,2500015991,CDM,637,RC,904663861,NDC,,,,,,outpatient,facility,25,UN,0.95,0.95,0.08,618.77,,0.55,,,percent of total billed charges,,,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.95,,,percent of total billed charges,,,0.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.85,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.35,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,0.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,0.95,,,fee schedule,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,0.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.67,,,percent of total billed charges,,
QUETIAPINE 25 MG TAB,2500015991,CDM,637,RC,904663861,NDC,999,EAPG,,,,outpatient,facility,25,UN,0.95,0.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
QUETIAPINE XR 200 MG,2500015993,CDM,637,RC,6818061407,NDC,,,,,,inpatient,facility,200,UN,57.85,57.85,4.63,57.85,,,,,,,,,,,,,,57.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.07,,,percent of total billed charges,,,,,,,,,57.85,,,percent of total billed charges,,,32.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.85,,,percent of total billed charges,,,,,,,,,,,,,,,57.85,,,percent of total billed charges,,,30.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,57.85,,,percent of total billed charges,,,57.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.62,,,percent of total billed charges,,
QUETIAPINE XR 200 MG,2500015993,CDM,637,RC,6818061407,NDC,,,,,,outpatient,facility,200,UN,57.85,57.85,4.63,618.77,,33.78,,,percent of total billed charges,,,11.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,57.85,,,percent of total billed charges,,,50.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,50.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,50.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,57.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,21.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,52.07,,,percent of total billed charges,,,,,,,,,57.85,,,percent of total billed charges,,,39.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.43,,,percent of total billed charges,,,,,,,,,,,,,,,31.24,,,percent of total billed charges,,,31.24,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,57.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.16,,,percent of total billed charges,,,57.85,,,percent of total billed charges,,,57.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.97,,,percent of total billed charges,,,21.91,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,11.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,21.4,,,percent of total billed charges,,,21.4,,,percent of total billed charges,,,57.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,57.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.63,,,percent of total billed charges,,,57.85,,,percent of total billed charges,,,57.85,,,percent of total billed charges,,,,,,,,,,,,,,,57.85,,,percent of total billed charges,,,57.85,,,percent of total billed charges,,,,,,,,,57.85,,,fee schedule,,,53.81,,,percent of total billed charges,,,,,,,,,,,,,,,53.81,,,percent of total billed charges,,,53.81,,,percent of total billed charges,,,53.81,,,percent of total billed charges,,,43.39,,,percent of total billed charges,,,57.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,57.85,,,percent of total billed charges,,,57.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,40.62,,,percent of total billed charges,,
QUETIAPINE XR 200 MG,2500015993,CDM,637,RC,6818061407,NDC,999,EAPG,,,,outpatient,facility,200,UN,57.85,57.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
QUETIAPINE 50 MG TAB,2500015995,CDM,637,RC,904663961,NDC,,,,,,inpatient,facility,50,UN,1.55,1.55,0.12,1.55,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,
QUETIAPINE 50 MG TAB,2500015995,CDM,637,RC,904663961,NDC,,,,,,outpatient,facility,50,UN,1.55,1.55,0.12,618.77,,0.91,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.55,,,percent of total billed charges,,,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.4,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.57,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,1.55,,,fee schedule,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.09,,,percent of total billed charges,,
QUETIAPINE 50 MG TAB,2500015995,CDM,637,RC,904663961,NDC,999,EAPG,,,,outpatient,facility,50,UN,1.55,1.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
QUETIAPINE 50 MG TABXR,2500015999,CDM,637,RC,6818061207,NDC,,,,,,inpatient,facility,50,UN,29.27,29.27,2.34,29.27,,,,,,,,,,,,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.34,,,percent of total billed charges,,,,,,,,,29.27,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,29.27,,,percent of total billed charges,,,15.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.55,,,percent of total billed charges,,
QUETIAPINE 50 MG TABXR,2500015999,CDM,637,RC,6818061207,NDC,,,,,,outpatient,facility,50,UN,29.27,29.27,2.34,618.77,,17.09,,,percent of total billed charges,,,5.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,29.27,,,percent of total billed charges,,,25.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,25.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,25.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26.34,,,percent of total billed charges,,,,,,,,,29.27,,,percent of total billed charges,,,19.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.48,,,percent of total billed charges,,,,,,,,,,,,,,,15.81,,,percent of total billed charges,,,15.81,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.26,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.25,,,percent of total billed charges,,,11.09,,,percent of total billed charges,,,15.16,,,percent of total billed charges,,,,,,,,,,,,,,,5.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.83,,,percent of total billed charges,,,10.83,,,percent of total billed charges,,,29.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.34,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,29.27,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,,,,,,,29.27,,,fee schedule,,,27.23,,,percent of total billed charges,,,,,,,,,,,,,,,27.23,,,percent of total billed charges,,,27.23,,,percent of total billed charges,,,27.23,,,percent of total billed charges,,,21.95,,,percent of total billed charges,,,29.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,29.27,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.55,,,percent of total billed charges,,
QUETIAPINE 50 MG TABXR,2500015999,CDM,637,RC,6818061207,NDC,999,EAPG,,,,outpatient,facility,50,UN,29.27,29.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RACEPINEPHRINE 2.25  NEB 0.5ML,2500016063,CDM,637,RC,487278401,NDC,,,,,,inpatient,facility,0.5,UN,7.25,7.25,0.58,7.25,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.53,,,percent of total billed charges,,,,,,,,,7.25,,,percent of total billed charges,,,4.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,3.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.09,,,percent of total billed charges,,
RACEPINEPHRINE 2.25  NEB 0.5ML,2500016063,CDM,637,RC,487278401,NDC,,,,,,outpatient,facility,0.5,UN,7.25,7.25,0.58,618.77,,4.23,,,percent of total billed charges,,,1.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.25,,,percent of total billed charges,,,6.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.53,,,percent of total billed charges,,,,,,,,,7.25,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.78,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.68,,,percent of total billed charges,,,2.68,,,percent of total billed charges,,,7.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.58,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,,,,,,,7.25,,,fee schedule,,,6.74,,,percent of total billed charges,,,,,,,,,,,,,,,6.74,,,percent of total billed charges,,,6.74,,,percent of total billed charges,,,6.74,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,7.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.25,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.09,,,percent of total billed charges,,
RACEPINEPHRINE 2.25  NEB 0.5ML,2500016063,CDM,637,RC,487278401,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,7.25,7.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RALOXIFENE HCL 60 MG TAB,2500016070,CDM,637,RC,5026869415,NDC,,,,,,inpatient,facility,60,UN,23.53,23.53,1.88,23.53,,,,,,,,,,,,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,percent of total billed charges,,,,,,,,,23.53,,,percent of total billed charges,,,13.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,23.53,,,percent of total billed charges,,,12.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.52,,,percent of total billed charges,,
RALOXIFENE HCL 60 MG TAB,2500016070,CDM,637,RC,5026869415,NDC,,,,,,outpatient,facility,60,UN,23.53,23.53,1.88,618.77,,13.74,,,percent of total billed charges,,,4.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,23.53,,,percent of total billed charges,,,20.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,20.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,20.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,21.18,,,percent of total billed charges,,,,,,,,,23.53,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.07,,,percent of total billed charges,,,,,,,,,,,,,,,12.71,,,percent of total billed charges,,,12.71,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.27,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.88,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,12.19,,,percent of total billed charges,,,,,,,,,,,,,,,4.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.71,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,23.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.88,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,23.53,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,,,,,,,23.53,,,fee schedule,,,21.89,,,percent of total billed charges,,,,,,,,,,,,,,,21.89,,,percent of total billed charges,,,21.89,,,percent of total billed charges,,,21.89,,,percent of total billed charges,,,17.65,,,percent of total billed charges,,,23.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,23.53,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,16.52,,,percent of total billed charges,,
RALOXIFENE HCL 60 MG TAB,2500016070,CDM,637,RC,5026869415,NDC,999,EAPG,,,,outpatient,facility,60,UN,23.53,23.53,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RAMELTEON 8 MG TAB,2500016075,CDM,637,RC,832125011,NDC,,,,,,inpatient,facility,8,UN,46.17,46.17,3.69,46.17,,,,,,,,,,,,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.55,,,percent of total billed charges,,,,,,,,,46.17,,,percent of total billed charges,,,25.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,46.17,,,percent of total billed charges,,,24.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.69,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.42,,,percent of total billed charges,,
RAMELTEON 8 MG TAB,2500016075,CDM,637,RC,832125011,NDC,,,,,,outpatient,facility,8,UN,46.17,46.17,3.69,618.77,,26.96,,,percent of total billed charges,,,9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,46.17,,,percent of total billed charges,,,40.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,40.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,40.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,41.55,,,percent of total billed charges,,,,,,,,,46.17,,,percent of total billed charges,,,31.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.46,,,percent of total billed charges,,,,,,,,,,,,,,,24.93,,,percent of total billed charges,,,24.93,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.07,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.09,,,percent of total billed charges,,,17.49,,,percent of total billed charges,,,23.91,,,percent of total billed charges,,,,,,,,,,,,,,,9.23,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,17.08,,,percent of total billed charges,,,17.08,,,percent of total billed charges,,,46.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.69,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,46.17,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,,,,,,,46.17,,,fee schedule,,,42.95,,,percent of total billed charges,,,,,,,,,,,,,,,42.95,,,percent of total billed charges,,,42.95,,,percent of total billed charges,,,42.95,,,percent of total billed charges,,,34.63,,,percent of total billed charges,,,46.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,46.17,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,32.42,,,percent of total billed charges,,
RAMELTEON 8 MG TAB,2500016075,CDM,637,RC,832125011,NDC,999,EAPG,,,,outpatient,facility,8,UN,46.17,46.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REMIFENTANIL 1 MG INJ,2500016110,CDM,250,RC,J3490,HCPCS,6332372303,NDC,,,,inpatient,facility,1,UN,241.92,241.92,19.35,241.92,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.73,,,percent of total billed charges,,,,,,,,,241.92,,,percent of total billed charges,,,133.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,126.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.35,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.88,,,percent of total billed charges,,
REMIFENTANIL 1 MG INJ,2500016110,CDM,250,RC,J3490,HCPCS,6332372303,NDC,,,,outpatient,facility,1,UN,241.92,241.92,1.2,618.77,,141.28,,,percent of total billed charges,,,47.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,241.92,,,percent of total billed charges,,,212.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,212.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,212.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,88.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,217.73,,,percent of total billed charges,,,,,,,,,241.92,,,percent of total billed charges,,,163.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.79,,,percent of total billed charges,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.14,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.86,,,percent of total billed charges,,,91.64,,,percent of total billed charges,,,125.29,,,percent of total billed charges,,,,,,,,,,,,,,,48.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,241.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,241.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.35,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,241.92,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,181.44,,,percent of total billed charges,,,241.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,169.88,,,percent of total billed charges,,
REMIFENTANIL 1 MG INJ,2500016110,CDM,250,RC,J3490,HCPCS,6332372303,NDC,435,EAPG,,outpatient,facility,1,UN,241.92,241.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REPAGLINIDE 1 MG TAB,2500016131,CDM,637,RC,5723715801,NDC,,,,,,inpatient,facility,1,UN,12.07,12.07,0.97,12.07,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.86,,,percent of total billed charges,,,,,,,,,12.07,,,percent of total billed charges,,,6.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,6.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,
REPAGLINIDE 1 MG TAB,2500016131,CDM,637,RC,5723715801,NDC,,,,,,outpatient,facility,1,UN,12.07,12.07,0.97,618.77,,7.05,,,percent of total billed charges,,,2.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,12.07,,,percent of total billed charges,,,10.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,10.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,10.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.86,,,percent of total billed charges,,,,,,,,,12.07,,,percent of total billed charges,,,8.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.27,,,percent of total billed charges,,,,,,,,,,,,,,,6.52,,,percent of total billed charges,,,6.52,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.29,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.17,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,6.25,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.47,,,percent of total billed charges,,,4.47,,,percent of total billed charges,,,12.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.97,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,,,,,,,12.07,,,fee schedule,,,11.23,,,percent of total billed charges,,,,,,,,,,,,,,,11.23,,,percent of total billed charges,,,11.23,,,percent of total billed charges,,,11.23,,,percent of total billed charges,,,9.05,,,percent of total billed charges,,,12.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,12.07,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.48,,,percent of total billed charges,,
REPAGLINIDE 1 MG TAB,2500016131,CDM,637,RC,5723715801,NDC,999,EAPG,,,,outpatient,facility,1,UN,12.07,12.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RISPERIDONE 0.25 MG TAB,2500016230,CDM,637,RC,904635761,NDC,,,,,,inpatient,facility,0.25,UN,0.56,0.56,0.04,0.56,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,
RISPERIDONE 0.25 MG TAB,2500016230,CDM,637,RC,904635761,NDC,,,,,,outpatient,facility,0.25,UN,0.56,0.56,0.04,618.77,,0.33,,,percent of total billed charges,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.5,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.56,,,fee schedule,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,0.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.39,,,percent of total billed charges,,
RISPERIDONE 0.25 MG TAB,2500016230,CDM,637,RC,904635761,NDC,999,EAPG,,,,outpatient,facility,0.25,UN,0.56,0.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RISPERIDONE 1 MG TAB,2500016232,CDM,637,RC,904635961,NDC,,,,,,inpatient,facility,1,UN,0.56,0.56,0.04,0.56,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,
RISPERIDONE 1 MG TAB,2500016232,CDM,637,RC,904635961,NDC,,,,,,outpatient,facility,1,UN,0.56,0.56,0.04,618.77,,0.33,,,percent of total billed charges,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.5,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.56,,,fee schedule,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,0.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.39,,,percent of total billed charges,,
RISPERIDONE 1 MG TAB,2500016232,CDM,637,RC,904635961,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.56,0.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RISPERIDONE 2 MG TAB,2500016233,CDM,637,RC,904636061,NDC,,,,,,inpatient,facility,2,UN,0.62,0.62,0.05,0.62,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,
RISPERIDONE 2 MG TAB,2500016233,CDM,637,RC,904636061,NDC,,,,,,outpatient,facility,2,UN,0.62,0.62,0.05,618.77,,0.36,,,percent of total billed charges,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.62,,,percent of total billed charges,,,0.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.56,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,0.62,,,fee schedule,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.44,,,percent of total billed charges,,
RISPERIDONE 2 MG TAB,2500016233,CDM,637,RC,904636061,NDC,999,EAPG,,,,outpatient,facility,2,UN,0.62,0.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RISPERIDONE 1 MG/ML SOL,2500016235,CDM,637,RC,6516267384,NDC,,,,,,inpatient,facility,1,UN,16.76,16.76,1.34,16.76,,,,,,,,,,,,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.08,,,percent of total billed charges,,,,,,,,,16.76,,,percent of total billed charges,,,9.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,16.76,,,percent of total billed charges,,,8.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.77,,,percent of total billed charges,,
RISPERIDONE 1 MG/ML SOL,2500016235,CDM,637,RC,6516267384,NDC,,,,,,outpatient,facility,1,UN,16.76,16.76,1.34,618.77,,9.79,,,percent of total billed charges,,,3.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.76,,,percent of total billed charges,,,14.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,14.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,14.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,15.08,,,percent of total billed charges,,,,,,,,,16.76,,,percent of total billed charges,,,11.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,9.05,,,percent of total billed charges,,,9.05,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.74,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,6.35,,,percent of total billed charges,,,8.68,,,percent of total billed charges,,,,,,,,,,,,,,,3.35,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.2,,,percent of total billed charges,,,6.2,,,percent of total billed charges,,,16.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.34,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,16.76,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,,,,,,,16.76,,,fee schedule,,,15.59,,,percent of total billed charges,,,,,,,,,,,,,,,15.59,,,percent of total billed charges,,,15.59,,,percent of total billed charges,,,15.59,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,16.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.76,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.77,,,percent of total billed charges,,
RISPERIDONE 1 MG/ML SOL,2500016235,CDM,637,RC,6516267384,NDC,999,EAPG,,,,outpatient,facility,1,UN,16.76,16.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIVAROXABAN 15 MG TAB,2500016258,CDM,637,RC,5045857810,NDC,,,,,,inpatient,facility,15,UN,62.67,62.67,5.01,62.67,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.4,,,percent of total billed charges,,,,,,,,,62.67,,,percent of total billed charges,,,34.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,32.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.01,,,percent of total billed charges,,
RIVAROXABAN 15 MG TAB,2500016258,CDM,637,RC,5045857810,NDC,,,,,,outpatient,facility,15,UN,62.67,62.67,5.01,618.77,,36.6,,,percent of total billed charges,,,12.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,62.67,,,percent of total billed charges,,,55.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,55.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,55.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,22.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,56.4,,,percent of total billed charges,,,,,,,,,62.67,,,percent of total billed charges,,,42.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.13,,,percent of total billed charges,,,,,,,,,,,,,,,33.84,,,percent of total billed charges,,,33.84,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.68,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.63,,,percent of total billed charges,,,23.74,,,percent of total billed charges,,,32.46,,,percent of total billed charges,,,,,,,,,,,,,,,12.53,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,23.19,,,percent of total billed charges,,,23.19,,,percent of total billed charges,,,62.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,62.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.01,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,62.67,,,fee schedule,,,58.3,,,percent of total billed charges,,,,,,,,,,,,,,,58.3,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,47,,,percent of total billed charges,,,62.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,44.01,,,percent of total billed charges,,
RIVAROXABAN 15 MG TAB,2500016258,CDM,637,RC,5045857810,NDC,999,EAPG,,,,outpatient,facility,15,UN,62.67,62.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIVAROXABAN 10 MG TAB,2500016259,CDM,637,RC,5045858010,NDC,,,,,,inpatient,facility,10,UN,62.66,62.66,5.01,62.66,,,,,,,,,,,,,,62.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.39,,,percent of total billed charges,,,,,,,,,62.66,,,percent of total billed charges,,,34.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.66,,,percent of total billed charges,,,,,,,,,,,,,,,62.66,,,percent of total billed charges,,,32.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,62.66,,,percent of total billed charges,,,62.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44,,,percent of total billed charges,,
RIVAROXABAN 10 MG TAB,2500016259,CDM,637,RC,5045858010,NDC,,,,,,outpatient,facility,10,UN,62.66,62.66,5.01,618.77,,36.59,,,percent of total billed charges,,,12.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,62.66,,,percent of total billed charges,,,55.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,55.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,55.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,62.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,22.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,56.39,,,percent of total billed charges,,,,,,,,,62.66,,,percent of total billed charges,,,42.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.12,,,percent of total billed charges,,,,,,,,,,,,,,,33.84,,,percent of total billed charges,,,33.84,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,62.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.67,,,percent of total billed charges,,,62.66,,,percent of total billed charges,,,62.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.62,,,percent of total billed charges,,,23.74,,,percent of total billed charges,,,32.45,,,percent of total billed charges,,,,,,,,,,,,,,,12.53,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,23.18,,,percent of total billed charges,,,23.18,,,percent of total billed charges,,,62.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,62.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.01,,,percent of total billed charges,,,62.66,,,percent of total billed charges,,,62.66,,,percent of total billed charges,,,,,,,,,,,,,,,62.66,,,percent of total billed charges,,,62.66,,,percent of total billed charges,,,,,,,,,62.66,,,fee schedule,,,58.29,,,percent of total billed charges,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,46.99,,,percent of total billed charges,,,62.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,62.66,,,percent of total billed charges,,,62.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.33,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,44,,,percent of total billed charges,,
RIVAROXABAN 10 MG TAB,2500016259,CDM,637,RC,5045858010,NDC,999,EAPG,,,,outpatient,facility,10,UN,62.66,62.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIVASTIGMINE TART 1.5 MG CAP,2500016260,CDM,637,RC,6586264860,NDC,,,,,,inpatient,facility,1.5,UN,15.38,15.38,1.23,15.38,,,,,,,,,,,,,,15.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.84,,,percent of total billed charges,,,,,,,,,15.38,,,percent of total billed charges,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.38,,,percent of total billed charges,,,,,,,,,,,,,,,15.38,,,percent of total billed charges,,,8.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,15.38,,,percent of total billed charges,,,15.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.8,,,percent of total billed charges,,
RIVASTIGMINE TART 1.5 MG CAP,2500016260,CDM,637,RC,6586264860,NDC,,,,,,outpatient,facility,1.5,UN,15.38,15.38,1.23,618.77,,8.98,,,percent of total billed charges,,,3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,15.38,,,percent of total billed charges,,,13.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,13.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,13.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.84,,,percent of total billed charges,,,,,,,,,15.38,,,percent of total billed charges,,,10.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.81,,,percent of total billed charges,,,,,,,,,,,,,,,8.31,,,percent of total billed charges,,,8.31,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,15.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.02,,,percent of total billed charges,,,15.38,,,percent of total billed charges,,,15.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.69,,,percent of total billed charges,,,5.83,,,percent of total billed charges,,,7.97,,,percent of total billed charges,,,,,,,,,,,,,,,3.08,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.69,,,percent of total billed charges,,,5.69,,,percent of total billed charges,,,15.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.23,,,percent of total billed charges,,,15.38,,,percent of total billed charges,,,15.38,,,percent of total billed charges,,,,,,,,,,,,,,,15.38,,,percent of total billed charges,,,15.38,,,percent of total billed charges,,,,,,,,,15.38,,,fee schedule,,,14.31,,,percent of total billed charges,,,,,,,,,,,,,,,14.31,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,11.54,,,percent of total billed charges,,,15.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,15.38,,,percent of total billed charges,,,15.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.8,,,percent of total billed charges,,
RIVASTIGMINE TART 1.5 MG CAP,2500016260,CDM,637,RC,6586264860,NDC,999,EAPG,,,,outpatient,facility,1.5,UN,15.38,15.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIVASTIGMINE 4.6 MG PATCH,2500016267,CDM,637,RC,4778130403,NDC,,,,,,inpatient,facility,1,UN,53.46,53.46,4.28,53.46,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,,,,,,,53.46,,,percent of total billed charges,,,29.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,27.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.54,,,percent of total billed charges,,
RIVASTIGMINE 4.6 MG PATCH,2500016267,CDM,637,RC,4778130403,NDC,,,,,,outpatient,facility,1,UN,53.46,53.46,4.28,618.77,,31.22,,,percent of total billed charges,,,10.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,53.46,,,percent of total billed charges,,,47.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,47.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,47.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,19.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,48.11,,,percent of total billed charges,,,,,,,,,53.46,,,percent of total billed charges,,,36.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.06,,,percent of total billed charges,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.87,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.63,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,10.69,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,19.78,,,percent of total billed charges,,,19.78,,,percent of total billed charges,,,53.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.28,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,53.46,,,fee schedule,,,49.73,,,percent of total billed charges,,,,,,,,,,,,,,,49.73,,,percent of total billed charges,,,49.73,,,percent of total billed charges,,,49.73,,,percent of total billed charges,,,40.09,,,percent of total billed charges,,,53.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,37.54,,,percent of total billed charges,,
RIVASTIGMINE 4.6 MG PATCH,2500016267,CDM,637,RC,4778130403,NDC,999,EAPG,,,,outpatient,facility,1,UN,53.46,53.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIVASTIGMINE 9.5 MG PATCH,2500016268,CDM,637,RC,4778130503,NDC,,,,,,inpatient,facility,1,UN,53.46,53.46,4.28,53.46,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,,,,,,,53.46,,,percent of total billed charges,,,29.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,27.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.54,,,percent of total billed charges,,
RIVASTIGMINE 9.5 MG PATCH,2500016268,CDM,637,RC,4778130503,NDC,,,,,,outpatient,facility,1,UN,53.46,53.46,4.28,618.77,,31.22,,,percent of total billed charges,,,10.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,53.46,,,percent of total billed charges,,,47.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,47.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,47.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,19.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,48.11,,,percent of total billed charges,,,,,,,,,53.46,,,percent of total billed charges,,,36.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.06,,,percent of total billed charges,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.87,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.63,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,10.69,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,19.78,,,percent of total billed charges,,,19.78,,,percent of total billed charges,,,53.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.28,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,53.46,,,fee schedule,,,49.73,,,percent of total billed charges,,,,,,,,,,,,,,,49.73,,,percent of total billed charges,,,49.73,,,percent of total billed charges,,,49.73,,,percent of total billed charges,,,40.09,,,percent of total billed charges,,,53.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,37.54,,,percent of total billed charges,,
RIVASTIGMINE 9.5 MG PATCH,2500016268,CDM,637,RC,4778130503,NDC,999,EAPG,,,,outpatient,facility,1,UN,53.46,53.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROCURONIUM 10 MG/ML 5 ML INJ,2500016275,CDM,250,RC,J3490,HCPCS,6332342605,NDC,,,,inpatient,facility,100,UN,34.65,34.65,2.77,34.65,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.18,,,percent of total billed charges,,,,,,,,,34.65,,,percent of total billed charges,,,19.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,18.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.33,,,percent of total billed charges,,
ROCURONIUM 10 MG/ML 5 ML INJ,2500016275,CDM,250,RC,J3490,HCPCS,6332342605,NDC,,,,outpatient,facility,100,UN,34.65,34.65,1.2,618.77,,20.24,,,percent of total billed charges,,,6.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,34.65,,,percent of total billed charges,,,30.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,30.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,30.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,12.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,31.18,,,percent of total billed charges,,,,,,,,,34.65,,,percent of total billed charges,,,23.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.61,,,percent of total billed charges,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.07,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.33,,,percent of total billed charges,,,13.13,,,percent of total billed charges,,,17.95,,,percent of total billed charges,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,34.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,34.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,34.65,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,25.99,,,percent of total billed charges,,,34.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,24.33,,,percent of total billed charges,,
ROCURONIUM 10 MG/ML 5 ML INJ,2500016275,CDM,250,RC,J3490,HCPCS,6332342605,NDC,435,EAPG,,outpatient,facility,100,UN,34.65,34.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROFLUMILAST 500 MCG TAB,2500016286,CDM,637,RC,310009530,NDC,,,,,,inpatient,facility,500,UN,48.81,48.81,3.9,48.81,,,,,,,,,,,,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.93,,,percent of total billed charges,,,,,,,,,48.81,,,percent of total billed charges,,,27.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,48.81,,,percent of total billed charges,,,25.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.27,,,percent of total billed charges,,
ROFLUMILAST 500 MCG TAB,2500016286,CDM,637,RC,310009530,NDC,,,,,,outpatient,facility,500,UN,48.81,48.81,3.9,618.77,,28.51,,,percent of total billed charges,,,9.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,48.81,,,percent of total billed charges,,,42.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,42.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,42.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,43.93,,,percent of total billed charges,,,,,,,,,48.81,,,percent of total billed charges,,,33.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.49,,,percent of total billed charges,,,,,,,,,,,,,,,26.36,,,percent of total billed charges,,,26.36,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.45,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.1,,,percent of total billed charges,,,18.49,,,percent of total billed charges,,,25.28,,,percent of total billed charges,,,,,,,,,,,,,,,9.76,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,18.06,,,percent of total billed charges,,,18.06,,,percent of total billed charges,,,48.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,48.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.9,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,48.81,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,,,,,,,48.81,,,fee schedule,,,45.4,,,percent of total billed charges,,,,,,,,,,,,,,,45.4,,,percent of total billed charges,,,45.4,,,percent of total billed charges,,,45.4,,,percent of total billed charges,,,36.61,,,percent of total billed charges,,,48.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,48.81,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,34.27,,,percent of total billed charges,,
ROFLUMILAST 500 MCG TAB,2500016286,CDM,637,RC,310009530,NDC,999,EAPG,,,,outpatient,facility,500,UN,48.81,48.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROPINIROLE HCL 0.25 MG TAB,2500016290,CDM,637,RC,4354726810,NDC,,,,,,inpatient,facility,0.25,UN,8.25,8.25,0.66,8.25,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.42,,,percent of total billed charges,,,,,,,,,8.25,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.79,,,percent of total billed charges,,
ROPINIROLE HCL 0.25 MG TAB,2500016290,CDM,637,RC,4354726810,NDC,,,,,,outpatient,facility,0.25,UN,8.25,8.25,0.66,618.77,,4.82,,,percent of total billed charges,,,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.25,,,percent of total billed charges,,,7.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.42,,,percent of total billed charges,,,,,,,,,8.25,,,percent of total billed charges,,,5.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,4.27,,,percent of total billed charges,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.05,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,8.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.66,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,8.25,,,fee schedule,,,7.67,,,percent of total billed charges,,,,,,,,,,,,,,,7.67,,,percent of total billed charges,,,7.67,,,percent of total billed charges,,,7.67,,,percent of total billed charges,,,6.19,,,percent of total billed charges,,,8.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.79,,,percent of total billed charges,,
ROPINIROLE HCL 0.25 MG TAB,2500016290,CDM,637,RC,4354726810,NDC,999,EAPG,,,,outpatient,facility,0.25,UN,8.25,8.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROPINIROLE HCL 1 MG TAB,2500016291,CDM,637,RC,4354727010,NDC,,,,,,inpatient,facility,1,UN,8.25,8.25,0.66,8.25,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.42,,,percent of total billed charges,,,,,,,,,8.25,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.79,,,percent of total billed charges,,
ROPINIROLE HCL 1 MG TAB,2500016291,CDM,637,RC,4354727010,NDC,,,,,,outpatient,facility,1,UN,8.25,8.25,0.66,618.77,,4.82,,,percent of total billed charges,,,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.25,,,percent of total billed charges,,,7.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.42,,,percent of total billed charges,,,,,,,,,8.25,,,percent of total billed charges,,,5.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,4.27,,,percent of total billed charges,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.05,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,8.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.66,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,8.25,,,fee schedule,,,7.67,,,percent of total billed charges,,,,,,,,,,,,,,,7.67,,,percent of total billed charges,,,7.67,,,percent of total billed charges,,,7.67,,,percent of total billed charges,,,6.19,,,percent of total billed charges,,,8.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.79,,,percent of total billed charges,,
ROPINIROLE HCL 1 MG TAB,2500016291,CDM,637,RC,4354727010,NDC,999,EAPG,,,,outpatient,facility,1,UN,8.25,8.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROPIVACAINE HCL 150 MG,2500016304,CDM,636,RC,J2795,HCPCS,6332328635,NDC,,,,inpatient,facility,30,UN,74.51,74.51,5.96,74.51,,,,,,,,,,,,,,74.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.06,,,percent of total billed charges,,,,,,,,,74.51,,,percent of total billed charges,,,41.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.51,,,percent of total billed charges,,,,,,,,,,,,,,,74.51,,,percent of total billed charges,,,38.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.96,,,percent of total billed charges,,,74.51,,,percent of total billed charges,,,74.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.32,,,percent of total billed charges,,
ROPIVACAINE HCL 150 MG,2500016304,CDM,636,RC,J2795,HCPCS,6332328635,NDC,,,,outpatient,facility,30,UN,74.51,74.51,0.08,618.77,,43.51,,,percent of total billed charges,,,14.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,74.51,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,74.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,27.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,67.06,,,percent of total billed charges,,,,,,,,,74.51,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,74.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.85,,,percent of total billed charges,,,74.51,,,percent of total billed charges,,,74.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.63,,,percent of total billed charges,,,28.22,,,percent of total billed charges,,,38.59,,,percent of total billed charges,,,,,,,,,,,,,,,14.9,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,74.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,74.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.96,,,percent of total billed charges,,,74.51,,,percent of total billed charges,,,74.51,,,percent of total billed charges,,,,,,,,,,,,,,,74.51,,,percent of total billed charges,,,74.51,,,percent of total billed charges,,,,,,,,,74.51,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.08,,,fee schedule,,,74.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,74.51,,,percent of total billed charges,,,74.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.26,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,52.32,,,percent of total billed charges,,
ROPIVACAINE HCL 150 MG,2500016304,CDM,636,RC,J2795,HCPCS,6332328635,NDC,496,EAPG,,outpatient,facility,30,UN,74.51,74.51,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SELENIUM SULF 1  SHAMP 120ML,2500016460,CDM,637,RC,536199553,NDC,,,,,,inpatient,facility,120,UN,2.52,2.52,0.2,2.52,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.27,,,percent of total billed charges,,,,,,,,,2.52,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,
SELENIUM SULF 1  SHAMP 120ML,2500016460,CDM,637,RC,536199553,NDC,,,,,,outpatient,facility,120,UN,2.52,2.52,0.2,618.77,,1.47,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.52,,,percent of total billed charges,,,2.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.27,,,percent of total billed charges,,,,,,,,,2.52,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.93,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,2.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,2.52,,,fee schedule,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,2.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.52,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.26,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.77,,,percent of total billed charges,,
SELENIUM SULF 1  SHAMP 120ML,2500016460,CDM,637,RC,536199553,NDC,999,EAPG,,,,outpatient,facility,120,UN,2.52,2.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SENNA 187 MG TAB,2500016470,CDM,637,RC,904652261,NDC,,,,,,inpatient,facility,8.6,UN,1.97,1.97,0.16,1.97,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,1.97,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,
SENNA 187 MG TAB,2500016470,CDM,637,RC,904652261,NDC,,,,,,outpatient,facility,8.6,UN,1.97,1.97,0.16,618.77,,1.15,,,percent of total billed charges,,,0.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.97,,,percent of total billed charges,,,1.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.77,,,percent of total billed charges,,,,,,,,,1.97,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,1.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,,,,,,,1.97,,,fee schedule,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,1.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.97,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.38,,,percent of total billed charges,,
SENNA 187 MG TAB,2500016470,CDM,637,RC,904652261,NDC,999,EAPG,,,,outpatient,facility,8.6,UN,1.97,1.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SERTRALINE HCL 50 MG TAB,2500016482,CDM,637,RC,904692561,NDC,,,,,,inpatient,facility,50,UN,1.32,1.32,0.11,1.32,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,
SERTRALINE HCL 50 MG TAB,2500016482,CDM,637,RC,904692561,NDC,,,,,,outpatient,facility,50,UN,1.32,1.32,0.11,618.77,,0.77,,,percent of total billed charges,,,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.32,,,percent of total billed charges,,,1.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.19,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,1.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,1.32,,,fee schedule,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,1.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.93,,,percent of total billed charges,,
SERTRALINE HCL 50 MG TAB,2500016482,CDM,637,RC,904692561,NDC,999,EAPG,,,,outpatient,facility,50,UN,1.32,1.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SILVER  NITR SWABS,2500016530,CDM,637,RC,1287000011,NDC,,,,,,inpatient,facility,1,UN,2.51,2.51,0.2,2.51,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,2.51,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,
SILVER  NITR SWABS,2500016530,CDM,637,RC,1287000011,NDC,,,,,,outpatient,facility,1,UN,2.51,2.51,0.2,618.77,,1.47,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.51,,,percent of total billed charges,,,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.26,,,percent of total billed charges,,,,,,,,,2.51,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.93,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,2.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,2.51,,,fee schedule,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,2.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.76,,,percent of total billed charges,,
SILVER  NITR SWABS,2500016530,CDM,637,RC,1287000011,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.51,2.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SILVER SULFADIAZINE 1  CR 50GM,2500016543,CDM,637,RC,6787712405,NDC,,,,,,inpatient,facility,50,UN,49.9,49.9,3.99,49.9,,,,,,,,,,,,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.91,,,percent of total billed charges,,,,,,,,,49.9,,,percent of total billed charges,,,27.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,49.9,,,percent of total billed charges,,,26.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.04,,,percent of total billed charges,,
SILVER SULFADIAZINE 1  CR 50GM,2500016543,CDM,637,RC,6787712405,NDC,,,,,,outpatient,facility,50,UN,49.9,49.9,3.99,618.77,,29.14,,,percent of total billed charges,,,9.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,49.9,,,percent of total billed charges,,,43.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,43.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,43.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,18.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,44.91,,,percent of total billed charges,,,,,,,,,49.9,,,percent of total billed charges,,,33.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.32,,,percent of total billed charges,,,,,,,,,,,,,,,26.95,,,percent of total billed charges,,,26.95,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.02,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.92,,,percent of total billed charges,,,18.9,,,percent of total billed charges,,,25.84,,,percent of total billed charges,,,,,,,,,,,,,,,9.98,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,18.46,,,percent of total billed charges,,,18.46,,,percent of total billed charges,,,49.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,49.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.99,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,49.9,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,,,,,,,49.9,,,fee schedule,,,46.42,,,percent of total billed charges,,,,,,,,,,,,,,,46.42,,,percent of total billed charges,,,46.42,,,percent of total billed charges,,,46.42,,,percent of total billed charges,,,37.42,,,percent of total billed charges,,,49.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,49.9,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.04,,,percent of total billed charges,,
SILVER SULFADIAZINE 1  CR 50GM,2500016543,CDM,637,RC,6787712405,NDC,999,EAPG,,,,outpatient,facility,50,UN,49.9,49.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIMETHICONE 80 MG CHEW TAB,2500016550,CDM,637,RC,5789679101,NDC,,,,,,inpatient,facility,80,UN,1.59,1.59,0.13,1.59,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,1.59,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,
SIMETHICONE 80 MG CHEW TAB,2500016550,CDM,637,RC,5789679101,NDC,,,,,,outpatient,facility,80,UN,1.59,1.59,0.13,618.77,,0.93,,,percent of total billed charges,,,0.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.59,,,percent of total billed charges,,,1.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.43,,,percent of total billed charges,,,,,,,,,1.59,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,1.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,1.59,,,fee schedule,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.59,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.12,,,percent of total billed charges,,
SIMETHICONE 80 MG CHEW TAB,2500016550,CDM,637,RC,5789679101,NDC,999,EAPG,,,,outpatient,facility,80,UN,1.59,1.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIMETHICONE 20 MG/0.3 ML UD,2500016554,CDM,637,RC,6237263015,NDC,,,,,,inpatient,facility,0.3,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
SIMETHICONE 20 MG/0.3 ML UD,2500016554,CDM,637,RC,6237263015,NDC,,,,,,outpatient,facility,0.3,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
SIMETHICONE 20 MG/0.3 ML UD,2500016554,CDM,637,RC,6237263015,NDC,999,EAPG,,,,outpatient,facility,0.3,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SINCALIDE 5 MCG INJ,2500016580,CDM,636,RC,J2805,HCPCS,270055615,NDC,,,,inpatient,facility,5,UN,491.5,491.5,39.32,491.5,,,,,,,,,,,,,,491.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.35,,,percent of total billed charges,,,,,,,,,491.5,,,percent of total billed charges,,,272.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,448.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.5,,,percent of total billed charges,,,,,,,,,,,,,,,491.5,,,percent of total billed charges,,,256.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.32,,,percent of total billed charges,,,491.5,,,percent of total billed charges,,,491.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,491.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.13,,,percent of total billed charges,,
SINCALIDE 5 MCG INJ,2500016580,CDM,636,RC,J2805,HCPCS,270055615,NDC,,,,outpatient,facility,5,UN,491.5,491.5,39.32,618.77,,287.04,,,percent of total billed charges,,,95.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,491.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,491.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,179.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,442.35,,,percent of total billed charges,,,,,,,,,491.5,,,percent of total billed charges,,,332.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,491.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,256.27,,,percent of total billed charges,,,491.5,,,percent of total billed charges,,,491.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.54,,,percent of total billed charges,,,186.18,,,percent of total billed charges,,,254.55,,,percent of total billed charges,,,,,,,,,,,,,,,98.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,491.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,491.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,39.32,,,percent of total billed charges,,,491.5,,,percent of total billed charges,,,491.5,,,percent of total billed charges,,,,,,,,,,,,,,,491.5,,,percent of total billed charges,,,491.5,,,percent of total billed charges,,,,,,,,,491.5,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,147.9,,,fee schedule,,,491.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,491.5,,,percent of total billed charges,,,491.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,345.13,,,percent of total billed charges,,
SINCALIDE 5 MCG INJ,2500016580,CDM,636,RC,J2805,HCPCS,270055615,NDC,999,EAPG,,outpatient,facility,5,UN,491.5,491.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD PHOS/BIPHOS ENEMA 133 ML,2500016620,CDM,637,RC,536741551,NDC,,,,,,inpatient,facility,133,UN,2.16,2.16,0.17,2.16,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,2.16,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,
SOD PHOS/BIPHOS ENEMA 133 ML,2500016620,CDM,637,RC,536741551,NDC,,,,,,outpatient,facility,133,UN,2.16,2.16,0.17,618.77,,1.26,,,percent of total billed charges,,,0.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.16,,,percent of total billed charges,,,1.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.94,,,percent of total billed charges,,,,,,,,,2.16,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.8,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,2.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,2.16,,,fee schedule,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,2.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.16,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.52,,,percent of total billed charges,,
SOD PHOS/BIPHOS ENEMA 133 ML,2500016620,CDM,637,RC,536741551,NDC,999,EAPG,,,,outpatient,facility,133,UN,2.16,2.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD POLYSTYRENE 15 GM/60 ML UD,2500016632,CDM,637,RC,4628700660,NDC,,,,,,inpatient,facility,60,UN,102.3,102.3,8.18,102.3,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.07,,,percent of total billed charges,,,,,,,,,102.3,,,percent of total billed charges,,,56.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,53.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.18,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.84,,,percent of total billed charges,,
SOD POLYSTYRENE 15 GM/60 ML UD,2500016632,CDM,637,RC,4628700660,NDC,,,,,,outpatient,facility,60,UN,102.3,102.3,8.18,618.77,,59.74,,,percent of total billed charges,,,19.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,102.3,,,percent of total billed charges,,,90.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,90.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,90.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,37.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,92.07,,,percent of total billed charges,,,,,,,,,102.3,,,percent of total billed charges,,,69.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.57,,,percent of total billed charges,,,,,,,,,,,,,,,55.24,,,percent of total billed charges,,,55.24,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.34,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.75,,,percent of total billed charges,,,38.75,,,percent of total billed charges,,,52.98,,,percent of total billed charges,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,37.85,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,102.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,102.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.18,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,,,,,,,102.3,,,fee schedule,,,95.16,,,percent of total billed charges,,,,,,,,,,,,,,,95.16,,,percent of total billed charges,,,95.16,,,percent of total billed charges,,,95.16,,,percent of total billed charges,,,76.72,,,percent of total billed charges,,,102.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,102.3,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,71.84,,,percent of total billed charges,,
SOD POLYSTYRENE 15 GM/60 ML UD,2500016632,CDM,637,RC,4628700660,NDC,999,EAPG,,,,outpatient,facility,60,UN,102.3,102.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD BICARB 4.2  10 ML SYR,2500016655,CDM,250,RC,409553424,NDC,,,,,,inpatient,facility,10,UN,35.67,35.67,2.85,35.67,,,,,,,,,,,,,,35.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.1,,,percent of total billed charges,,,,,,,,,35.67,,,percent of total billed charges,,,19.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.67,,,percent of total billed charges,,,,,,,,,,,,,,,35.67,,,percent of total billed charges,,,18.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,
SOD BICARB 4.2  10 ML SYR,2500016655,CDM,250,RC,409553424,NDC,,,,,,outpatient,facility,10,UN,35.67,35.67,2.85,618.77,,20.83,,,percent of total billed charges,,,6.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,35.67,,,percent of total billed charges,,,31.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,31.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,31.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,35.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,13.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,32.1,,,percent of total billed charges,,,,,,,,,35.67,,,percent of total billed charges,,,24.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,35.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.11,,,percent of total billed charges,,,13.51,,,percent of total billed charges,,,18.47,,,percent of total billed charges,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,14.27,,,percent of total billed charges,,,14.27,,,percent of total billed charges,,,35.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.85,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,,,,,,,,,,,,,35.67,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,,,,,,,35.67,,,fee schedule,,,14.27,,,percent of total billed charges,,,,,,,,,,,,,,,14.27,,,percent of total billed charges,,,14.27,,,percent of total billed charges,,,14.27,,,percent of total billed charges,,,26.75,,,percent of total billed charges,,,35.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,35.67,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,25.05,,,percent of total billed charges,,
SOD BICARB 4.2  10 ML SYR,2500016655,CDM,250,RC,409553424,NDC,999,EAPG,,,,outpatient,facility,10,UN,35.67,35.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD BICARB 8.4  50 ML SYR,2500016657,CDM,250,RC,J3490,HCPCS,409663714,NDC,,,,inpatient,facility,50,UN,63.29,63.29,5.06,63.29,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.96,,,percent of total billed charges,,,,,,,,,63.29,,,percent of total billed charges,,,35.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.44,,,percent of total billed charges,,
SOD BICARB 8.4  50 ML SYR,2500016657,CDM,250,RC,J3490,HCPCS,409663714,NDC,,,,outpatient,facility,50,UN,63.29,63.29,1.2,618.77,,36.96,,,percent of total billed charges,,,12.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,63.29,,,percent of total billed charges,,,55.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,55.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,55.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,23.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,56.96,,,percent of total billed charges,,,,,,,,,63.29,,,percent of total billed charges,,,42.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.61,,,percent of total billed charges,,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.1,,,percent of total billed charges,,,23.97,,,percent of total billed charges,,,32.78,,,percent of total billed charges,,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,63.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,63.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.06,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,,,,,,,63.29,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,47.47,,,percent of total billed charges,,,63.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,63.29,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,44.44,,,percent of total billed charges,,
SOD BICARB 8.4  50 ML SYR,2500016657,CDM,250,RC,J3490,HCPCS,409663714,NDC,435,EAPG,,outpatient,facility,50,UN,63.29,63.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD BICARB 8.4  50 ML INJ,2500016658,CDM,250,RC,6332308950,NDC,,,,,,inpatient,facility,50,UN,28.87,28.87,2.31,28.87,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.98,,,percent of total billed charges,,,,,,,,,28.87,,,percent of total billed charges,,,15.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,15.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.27,,,percent of total billed charges,,
SOD BICARB 8.4  50 ML INJ,2500016658,CDM,250,RC,6332308950,NDC,,,,,,outpatient,facility,50,UN,28.87,28.87,2.31,618.77,,16.86,,,percent of total billed charges,,,5.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,28.87,,,percent of total billed charges,,,25.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,25.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,25.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,25.98,,,percent of total billed charges,,,,,,,,,28.87,,,percent of total billed charges,,,19.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.05,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,10.94,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,28.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.31,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,28.87,,,fee schedule,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,21.65,,,percent of total billed charges,,,28.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,28.87,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.27,,,percent of total billed charges,,
SOD BICARB 8.4  50 ML INJ,2500016658,CDM,250,RC,6332308950,NDC,999,EAPG,,,,outpatient,facility,50,UN,28.87,28.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD BICARB 650 MG TAB,2500016660,CDM,637,RC,7733383110,NDC,,,,,,inpatient,facility,650,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
SOD BICARB 650 MG TAB,2500016660,CDM,637,RC,7733383110,NDC,,,,,,outpatient,facility,650,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
SOD BICARB 650 MG TAB,2500016660,CDM,637,RC,7733383110,NDC,999,EAPG,,,,outpatient,facility,650,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.9  GEL,2500016677,CDM,637,RC,592800099,NDC,,,,,,inpatient,facility,30,UN,12.66,12.66,1.01,12.66,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.39,,,percent of total billed charges,,,,,,,,,12.66,,,percent of total billed charges,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.89,,,percent of total billed charges,,
SOD CHLORIDE 0.9  GEL,2500016677,CDM,637,RC,592800099,NDC,,,,,,outpatient,facility,30,UN,12.66,12.66,1.01,618.77,,7.39,,,percent of total billed charges,,,2.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,12.66,,,percent of total billed charges,,,11.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,11.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,11.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.39,,,percent of total billed charges,,,,,,,,,12.66,,,percent of total billed charges,,,8.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.72,,,percent of total billed charges,,,,,,,,,,,,,,,6.84,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.62,,,percent of total billed charges,,,4.8,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,12.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.01,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,,,,,,,12.66,,,fee schedule,,,11.78,,,percent of total billed charges,,,,,,,,,,,,,,,11.78,,,percent of total billed charges,,,11.78,,,percent of total billed charges,,,11.78,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,12.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,12.66,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.33,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.89,,,percent of total billed charges,,
SOD CHLORIDE 0.9  GEL,2500016677,CDM,637,RC,592800099,NDC,999,EAPG,,,,outpatient,facility,30,UN,12.66,12.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.65  NASAL 45ML,2500016683,CDM,637,RC,904386575,NDC,,,,,,inpatient,facility,45,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
SOD CHLORIDE 0.65  NASAL 45ML,2500016683,CDM,637,RC,904386575,NDC,,,,,,outpatient,facility,45,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
SOD CHLORIDE 0.65  NASAL 45ML,2500016683,CDM,637,RC,904386575,NDC,999,EAPG,,,,outpatient,facility,45,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.9  3 ML INHA,2500016685,CDM,637,RC,J7699,HCPCS,487930103,NDC,,,,inpatient,facility,3,UN,0.99,0.99,0.08,0.99,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,
SOD CHLORIDE 0.9  3 ML INHA,2500016685,CDM,637,RC,J7699,HCPCS,487930103,NDC,,,,outpatient,facility,3,UN,0.99,0.99,0.08,618.77,,0.58,,,percent of total billed charges,,,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.99,,,percent of total billed charges,,,0.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.89,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,fee schedule,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.7,,,percent of total billed charges,,
SOD CHLORIDE 0.9  3 ML INHA,2500016685,CDM,637,RC,J7699,HCPCS,487930103,NDC,435,EAPG,,outpatient,facility,3,UN,0.99,0.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.9  IRRIG 1000ML,2500016686,CDM,637,RC,264220100,NDC,,,,,,inpatient,facility,1000,UN,13.2,13.2,1.06,13.2,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,6.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.27,,,percent of total billed charges,,
SOD CHLORIDE 0.9  IRRIG 1000ML,2500016686,CDM,637,RC,264220100,NDC,,,,,,outpatient,facility,1000,UN,13.2,13.2,1.06,618.77,,7.71,,,percent of total billed charges,,,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.2,,,percent of total billed charges,,,11.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,11.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,11.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.88,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.14,,,percent of total billed charges,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.88,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,5,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.88,,,percent of total billed charges,,,4.88,,,percent of total billed charges,,,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,13.2,,,fee schedule,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,13.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.27,,,percent of total billed charges,,
SOD CHLORIDE 0.9  IRRIG 1000ML,2500016686,CDM,637,RC,264220100,NDC,999,EAPG,,,,outpatient,facility,1000,UN,13.2,13.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.9  IRR 2000ML,2500016688,CDM,258,RC,990797207,NDC,,,,,,inpatient,facility,2000,UN,27.85,27.85,2.23,27.85,,,,,,,,,,,,,,27.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.07,,,percent of total billed charges,,,,,,,,,27.85,,,percent of total billed charges,,,15.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.85,,,percent of total billed charges,,,,,,,,,,,,,,,27.85,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,27.85,,,percent of total billed charges,,,27.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.56,,,percent of total billed charges,,
SOD CHLORIDE 0.9  IRR 2000ML,2500016688,CDM,258,RC,990797207,NDC,,,,,,outpatient,facility,2000,UN,27.85,27.85,2.23,618.77,,16.26,,,percent of total billed charges,,,5.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,27.85,,,percent of total billed charges,,,24.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,24.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,24.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,27.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,25.07,,,percent of total billed charges,,,,,,,,,27.85,,,percent of total billed charges,,,18.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,27.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,27.85,,,percent of total billed charges,,,27.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.17,,,percent of total billed charges,,,10.55,,,percent of total billed charges,,,14.42,,,percent of total billed charges,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,11.14,,,percent of total billed charges,,,11.14,,,percent of total billed charges,,,27.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.23,,,percent of total billed charges,,,27.85,,,percent of total billed charges,,,27.85,,,percent of total billed charges,,,,,,,,,,,,,,,27.85,,,percent of total billed charges,,,27.85,,,percent of total billed charges,,,,,,,,,27.85,,,fee schedule,,,11.14,,,percent of total billed charges,,,,,,,,,,,,,,,11.14,,,percent of total billed charges,,,11.14,,,percent of total billed charges,,,11.14,,,percent of total billed charges,,,20.89,,,percent of total billed charges,,,27.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,27.85,,,percent of total billed charges,,,27.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,19.56,,,percent of total billed charges,,
SOD CHLORIDE 0.9  IRR 2000ML,2500016688,CDM,258,RC,990797207,NDC,999,EAPG,,,,outpatient,facility,2000,UN,27.85,27.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 1 GM TAB,2500016690,CDM,637,RC,6936722001,NDC,,,,,,inpatient,facility,1,UN,1.94,1.94,0.16,1.94,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,
SOD CHLORIDE 1 GM TAB,2500016690,CDM,637,RC,6936722001,NDC,,,,,,outpatient,facility,1,UN,1.94,1.94,0.16,618.77,,1.13,,,percent of total billed charges,,,0.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.94,,,percent of total billed charges,,,1.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.75,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.72,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,1.94,,,fee schedule,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,1.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.36,,,percent of total billed charges,,
SOD CHLORIDE 1 GM TAB,2500016690,CDM,637,RC,6936722001,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.94,1.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 3  500 ML,2500016695,CDM,636,RC,J7131,HCPCS,6332353075,NDC,,,,inpatient,facility,500,UN,13.2,13.2,1.06,13.2,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,6.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.27,,,percent of total billed charges,,
SOD CHLORIDE 3  500 ML,2500016695,CDM,636,RC,J7131,HCPCS,6332353075,NDC,,,,outpatient,facility,500,UN,13.2,13.2,1.06,618.77,,7.71,,,percent of total billed charges,,,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.88,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.88,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,5,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,13.2,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,9.9,,,percent of total billed charges,,,13.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.27,,,percent of total billed charges,,
SOD CHLORIDE 3  500 ML,2500016695,CDM,636,RC,J7131,HCPCS,6332353075,NDC,496,EAPG,,outpatient,facility,500,UN,13.2,13.2,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 5  OP OINT 3.5 GM,2500016700,CDM,637,RC,536125391,NDC,,,,,,inpatient,facility,3.5,UN,15.24,15.24,1.22,15.24,,,,,,,,,,,,,,15.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,,,,,,,15.24,,,percent of total billed charges,,,8.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.24,,,percent of total billed charges,,,,,,,,,,,,,,,15.24,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,15.24,,,percent of total billed charges,,,15.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.7,,,percent of total billed charges,,
SOD CHLORIDE 5  OP OINT 3.5 GM,2500016700,CDM,637,RC,536125391,NDC,,,,,,outpatient,facility,3.5,UN,15.24,15.24,1.22,618.77,,8.9,,,percent of total billed charges,,,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,15.24,,,percent of total billed charges,,,13.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,13.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,13.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.72,,,percent of total billed charges,,,,,,,,,15.24,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.7,,,percent of total billed charges,,,,,,,,,,,,,,,8.23,,,percent of total billed charges,,,8.23,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,15.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,15.24,,,percent of total billed charges,,,15.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.58,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,3.05,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.64,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,15.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.22,,,percent of total billed charges,,,15.24,,,percent of total billed charges,,,15.24,,,percent of total billed charges,,,,,,,,,,,,,,,15.24,,,percent of total billed charges,,,15.24,,,percent of total billed charges,,,,,,,,,15.24,,,fee schedule,,,14.18,,,percent of total billed charges,,,,,,,,,,,,,,,14.18,,,percent of total billed charges,,,14.18,,,percent of total billed charges,,,14.18,,,percent of total billed charges,,,11.43,,,percent of total billed charges,,,15.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,15.24,,,percent of total billed charges,,,15.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.62,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.7,,,percent of total billed charges,,
SOD CHLORIDE 5  OP OINT 3.5 GM,2500016700,CDM,637,RC,536125391,NDC,999,EAPG,,,,outpatient,facility,3.5,UN,15.24,15.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 3  NEB 15 ML,2500016705,CDM,637,RC,378699789,NDC,,,,,,inpatient,facility,15,UN,2.48,2.48,0.2,2.48,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,,,,2.48,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,
SOD CHLORIDE 3  NEB 15 ML,2500016705,CDM,637,RC,378699789,NDC,,,,,,outpatient,facility,15,UN,2.48,2.48,0.2,618.77,,1.45,,,percent of total billed charges,,,0.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.48,,,percent of total billed charges,,,2.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.23,,,percent of total billed charges,,,,,,,,,2.48,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,2.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,2.48,,,fee schedule,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,2.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.74,,,percent of total billed charges,,
SOD CHLORIDE 3  NEB 15 ML,2500016705,CDM,637,RC,378699789,NDC,999,EAPG,,,,outpatient,facility,15,UN,2.48,2.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.9 IRR 3000 ML,2500016707,CDM,258,RC,990797208,NDC,,,,,,inpatient,facility,3000,UN,32.77,32.77,2.62,32.77,,,,,,,,,,,,,,32.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.49,,,percent of total billed charges,,,,,,,,,32.77,,,percent of total billed charges,,,18.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.77,,,percent of total billed charges,,,,,,,,,,,,,,,32.77,,,percent of total billed charges,,,17.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,32.77,,,percent of total billed charges,,,32.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.01,,,percent of total billed charges,,
SOD CHLORIDE 0.9 IRR 3000 ML,2500016707,CDM,258,RC,990797208,NDC,,,,,,outpatient,facility,3000,UN,32.77,32.77,2.62,618.77,,19.14,,,percent of total billed charges,,,6.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,32.77,,,percent of total billed charges,,,28.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,28.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,28.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,32.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,29.49,,,percent of total billed charges,,,,,,,,,32.77,,,percent of total billed charges,,,22.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,32.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.09,,,percent of total billed charges,,,32.77,,,percent of total billed charges,,,32.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.91,,,percent of total billed charges,,,12.41,,,percent of total billed charges,,,16.97,,,percent of total billed charges,,,,,,,,,,,,,,,6.55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,13.11,,,percent of total billed charges,,,13.11,,,percent of total billed charges,,,32.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.62,,,percent of total billed charges,,,32.77,,,percent of total billed charges,,,32.77,,,percent of total billed charges,,,,,,,,,,,,,,,32.77,,,percent of total billed charges,,,32.77,,,percent of total billed charges,,,,,,,,,32.77,,,fee schedule,,,13.11,,,percent of total billed charges,,,,,,,,,,,,,,,13.11,,,percent of total billed charges,,,13.11,,,percent of total billed charges,,,13.11,,,percent of total billed charges,,,24.58,,,percent of total billed charges,,,32.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,32.77,,,percent of total billed charges,,,32.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,23.01,,,percent of total billed charges,,
SOD CHLORIDE 0.9 IRR 3000 ML,2500016707,CDM,258,RC,990797208,NDC,999,EAPG,,,,outpatient,facility,3000,UN,32.77,32.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD HYPOCHLORITE 1/4 480ML,2500016738,CDM,250,RC,3932806412,NDC,,,,,,inpatient,facility,480,UN,26.64,26.64,2.13,26.64,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.98,,,percent of total billed charges,,,,,,,,,26.64,,,percent of total billed charges,,,14.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,13.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,
SOD HYPOCHLORITE 1/4 480ML,2500016738,CDM,250,RC,3932806412,NDC,,,,,,outpatient,facility,480,UN,26.64,26.64,2.13,618.77,,15.56,,,percent of total billed charges,,,5.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,26.64,,,percent of total billed charges,,,23.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,23.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,23.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,23.98,,,percent of total billed charges,,,,,,,,,26.64,,,percent of total billed charges,,,18.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.89,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.25,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,13.8,,,percent of total billed charges,,,,,,,,,,,,,,,5.33,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.66,,,percent of total billed charges,,,10.66,,,percent of total billed charges,,,26.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.13,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,,,,,,,26.64,,,fee schedule,,,10.66,,,percent of total billed charges,,,,,,,,,,,,,,,10.66,,,percent of total billed charges,,,10.66,,,percent of total billed charges,,,10.66,,,percent of total billed charges,,,19.98,,,percent of total billed charges,,,26.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,26.64,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,18.71,,,percent of total billed charges,,
SOD HYPOCHLORITE 1/4 480ML,2500016738,CDM,250,RC,3932806412,NDC,999,EAPG,,,,outpatient,facility,480,UN,26.64,26.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD PHOSPHATE 3 MM/ML 15ML INJ,2500016753,CDM,250,RC,409739172,NDC,,,,,,inpatient,facility,15,UN,60.32,60.32,4.83,60.32,,,,,,,,,,,,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.29,,,percent of total billed charges,,,,,,,,,60.32,,,percent of total billed charges,,,33.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,60.32,,,percent of total billed charges,,,31.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.83,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.36,,,percent of total billed charges,,
SOD PHOSPHATE 3 MM/ML 15ML INJ,2500016753,CDM,250,RC,409739172,NDC,,,,,,outpatient,facility,15,UN,60.32,60.32,4.83,618.77,,35.23,,,percent of total billed charges,,,11.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,60.32,,,percent of total billed charges,,,53.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,53.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,53.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,22.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,54.29,,,percent of total billed charges,,,,,,,,,60.32,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.45,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.84,,,percent of total billed charges,,,22.85,,,percent of total billed charges,,,31.24,,,percent of total billed charges,,,,,,,,,,,,,,,12.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,24.13,,,percent of total billed charges,,,24.13,,,percent of total billed charges,,,60.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,60.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.83,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,60.32,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,,,,,,,60.32,,,fee schedule,,,24.13,,,percent of total billed charges,,,,,,,,,,,,,,,24.13,,,percent of total billed charges,,,24.13,,,percent of total billed charges,,,24.13,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,60.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,60.32,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,42.36,,,percent of total billed charges,,
SOD PHOSPHATE 3 MM/ML 15ML INJ,2500016753,CDM,250,RC,409739172,NDC,999,EAPG,,,,outpatient,facility,15,UN,60.32,60.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOTALOL HCL 80 MG TAB,2500016794,CDM,637,RC,6050500800,NDC,,,,,,inpatient,facility,80,UN,8.45,8.45,0.68,8.45,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.6,,,percent of total billed charges,,,,,,,,,8.45,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,4.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.93,,,percent of total billed charges,,
SOTALOL HCL 80 MG TAB,2500016794,CDM,637,RC,6050500800,NDC,,,,,,outpatient,facility,80,UN,8.45,8.45,0.68,618.77,,4.93,,,percent of total billed charges,,,1.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.45,,,percent of total billed charges,,,7.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.6,,,percent of total billed charges,,,,,,,,,8.45,,,percent of total billed charges,,,5.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.49,,,percent of total billed charges,,,,,,,,,,,,,,,4.56,,,percent of total billed charges,,,4.56,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.41,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.42,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,8.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.68,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,8.45,,,fee schedule,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,8.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.93,,,percent of total billed charges,,
SOTALOL HCL 80 MG TAB,2500016794,CDM,637,RC,6050500800,NDC,999,EAPG,,,,outpatient,facility,80,UN,8.45,8.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPIRONOLACTONE 25 MG TAB,2500016803,CDM,637,RC,904692761,NDC,,,,,,inpatient,facility,25,UN,0.52,0.52,0.04,0.52,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,0.52,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,
SPIRONOLACTONE 25 MG TAB,2500016803,CDM,637,RC,904692761,NDC,,,,,,outpatient,facility,25,UN,0.52,0.52,0.04,618.77,,0.3,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.52,,,percent of total billed charges,,,0.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.47,,,percent of total billed charges,,,,,,,,,0.52,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.19,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,0.52,,,fee schedule,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.37,,,percent of total billed charges,,
SPIRONOLACTONE 25 MG TAB,2500016803,CDM,637,RC,904692761,NDC,999,EAPG,,,,outpatient,facility,25,UN,0.52,0.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUCRALFATE 1 GM TAB,2500016860,CDM,637,RC,93221001,NDC,,,,,,inpatient,facility,1,UN,2.64,2.64,0.21,2.64,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,
SUCRALFATE 1 GM TAB,2500016860,CDM,637,RC,93221001,NDC,,,,,,outpatient,facility,1,UN,2.64,2.64,0.21,618.77,,1.54,,,percent of total billed charges,,,0.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.64,,,percent of total billed charges,,,2.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.38,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.98,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,2.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,2.64,,,fee schedule,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,2.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.85,,,percent of total billed charges,,
SUCRALFATE 1 GM TAB,2500016860,CDM,637,RC,93221001,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.64,2.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUCRALFATE 1 GM/10 ML UDC,2500016861,CDM,637,RC,121074740,NDC,,,,,,inpatient,facility,10,UN,40.19,40.19,3.22,40.19,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.17,,,percent of total billed charges,,,,,,,,,40.19,,,percent of total billed charges,,,22.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,20.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.22,,,percent of total billed charges,,
SUCRALFATE 1 GM/10 ML UDC,2500016861,CDM,637,RC,121074740,NDC,,,,,,outpatient,facility,10,UN,40.19,40.19,3.22,618.77,,23.47,,,percent of total billed charges,,,7.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,40.19,,,percent of total billed charges,,,35.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,35.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,35.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,14.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,36.17,,,percent of total billed charges,,,,,,,,,40.19,,,percent of total billed charges,,,27.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.87,,,percent of total billed charges,,,,,,,,,,,,,,,21.7,,,percent of total billed charges,,,21.7,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.96,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.54,,,percent of total billed charges,,,15.22,,,percent of total billed charges,,,20.81,,,percent of total billed charges,,,,,,,,,,,,,,,8.04,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,14.87,,,percent of total billed charges,,,14.87,,,percent of total billed charges,,,40.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.22,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,,,,,,,40.19,,,fee schedule,,,37.38,,,percent of total billed charges,,,,,,,,,,,,,,,37.38,,,percent of total billed charges,,,37.38,,,percent of total billed charges,,,37.38,,,percent of total billed charges,,,30.14,,,percent of total billed charges,,,40.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,40.19,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,28.22,,,percent of total billed charges,,
SUCRALFATE 1 GM/10 ML UDC,2500016861,CDM,637,RC,121074740,NDC,999,EAPG,,,,outpatient,facility,10,UN,40.19,40.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SULFACETAMIDE 10  OPH 15 ML,2500016902,CDM,637,RC,2420867004,NDC,,,,,,inpatient,facility,15,UN,201.3,201.3,16.1,201.3,,,,,,,,,,,,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.17,,,percent of total billed charges,,,,,,,,,201.3,,,percent of total billed charges,,,111.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,201.3,,,percent of total billed charges,,,104.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.1,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.35,,,percent of total billed charges,,
SULFACETAMIDE 10  OPH 15 ML,2500016902,CDM,637,RC,2420867004,NDC,,,,,,outpatient,facility,15,UN,201.3,201.3,16.1,618.77,,117.56,,,percent of total billed charges,,,39.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,201.3,,,percent of total billed charges,,,177.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,177.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,177.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,73.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,181.17,,,percent of total billed charges,,,,,,,,,201.3,,,percent of total billed charges,,,136.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.6,,,percent of total billed charges,,,,,,,,,,,,,,,108.7,,,percent of total billed charges,,,108.7,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,104.96,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.99,,,percent of total billed charges,,,76.25,,,percent of total billed charges,,,104.25,,,percent of total billed charges,,,,,,,,,,,,,,,40.26,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,74.48,,,percent of total billed charges,,,74.48,,,percent of total billed charges,,,201.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,201.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.1,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,201.3,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,,,,,,,201.3,,,fee schedule,,,187.25,,,percent of total billed charges,,,,,,,,,,,,,,,187.25,,,percent of total billed charges,,,187.25,,,percent of total billed charges,,,187.25,,,percent of total billed charges,,,150.98,,,percent of total billed charges,,,201.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,201.3,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,141.35,,,percent of total billed charges,,
SULFACETAMIDE 10  OPH 15 ML,2500016902,CDM,637,RC,2420867004,NDC,999,EAPG,,,,outpatient,facility,15,UN,201.3,201.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SULFASALAZINE 500 MG TAB,2500016950,CDM,637,RC,5976250005,NDC,,,,,,inpatient,facility,500,UN,0.62,0.62,0.05,0.62,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,
SULFASALAZINE 500 MG TAB,2500016950,CDM,637,RC,5976250005,NDC,,,,,,outpatient,facility,500,UN,0.62,0.62,0.05,618.77,,0.36,,,percent of total billed charges,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.62,,,percent of total billed charges,,,0.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.56,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,0.62,,,fee schedule,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.44,,,percent of total billed charges,,
SULFASALAZINE 500 MG TAB,2500016950,CDM,637,RC,5976250005,NDC,999,EAPG,,,,outpatient,facility,500,UN,0.62,0.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUMATRIPTAN SUCC 25 MG TAB,2500017010,CDM,637,RC,6586214636,NDC,,,,,,inpatient,facility,25,UN,89.26,89.26,7.14,89.26,,,,,,,,,,,,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.33,,,percent of total billed charges,,,,,,,,,89.26,,,percent of total billed charges,,,49.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,89.26,,,percent of total billed charges,,,46.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.14,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.68,,,percent of total billed charges,,
SUMATRIPTAN SUCC 25 MG TAB,2500017010,CDM,637,RC,6586214636,NDC,,,,,,outpatient,facility,25,UN,89.26,89.26,7.14,618.77,,52.13,,,percent of total billed charges,,,17.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,89.26,,,percent of total billed charges,,,78.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,78.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,78.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,32.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,80.33,,,percent of total billed charges,,,,,,,,,89.26,,,percent of total billed charges,,,60.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.55,,,percent of total billed charges,,,,,,,,,,,,,,,48.2,,,percent of total billed charges,,,48.2,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.54,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.84,,,percent of total billed charges,,,33.81,,,percent of total billed charges,,,46.23,,,percent of total billed charges,,,,,,,,,,,,,,,17.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,33.03,,,percent of total billed charges,,,33.03,,,percent of total billed charges,,,89.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,89.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.14,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,89.26,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,,,,,,,89.26,,,fee schedule,,,83.03,,,percent of total billed charges,,,,,,,,,,,,,,,83.03,,,percent of total billed charges,,,83.03,,,percent of total billed charges,,,83.03,,,percent of total billed charges,,,66.95,,,percent of total billed charges,,,89.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,89.26,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,62.68,,,percent of total billed charges,,
SUMATRIPTAN SUCC 25 MG TAB,2500017010,CDM,637,RC,6586214636,NDC,999,EAPG,,,,outpatient,facility,25,UN,89.26,89.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUMATRIPTAN SUCC 100 MG TAB,2500017012,CDM,637,RC,6586214836,NDC,,,,,,inpatient,facility,100,UN,82.96,82.96,6.64,82.96,,,,,,,,,,,,,,82.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.66,,,percent of total billed charges,,,,,,,,,82.96,,,percent of total billed charges,,,45.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.96,,,percent of total billed charges,,,,,,,,,,,,,,,82.96,,,percent of total billed charges,,,43.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.64,,,percent of total billed charges,,,82.96,,,percent of total billed charges,,,82.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.25,,,percent of total billed charges,,
SUMATRIPTAN SUCC 100 MG TAB,2500017012,CDM,637,RC,6586214836,NDC,,,,,,outpatient,facility,100,UN,82.96,82.96,6.64,618.77,,48.45,,,percent of total billed charges,,,16.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,82.96,,,percent of total billed charges,,,73.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,73.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,73.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,82.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,30.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,74.66,,,percent of total billed charges,,,,,,,,,82.96,,,percent of total billed charges,,,56.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.71,,,percent of total billed charges,,,,,,,,,,,,,,,44.8,,,percent of total billed charges,,,44.8,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,82.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.26,,,percent of total billed charges,,,82.96,,,percent of total billed charges,,,82.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.05,,,percent of total billed charges,,,31.43,,,percent of total billed charges,,,42.96,,,percent of total billed charges,,,,,,,,,,,,,,,16.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,30.7,,,percent of total billed charges,,,30.7,,,percent of total billed charges,,,82.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,82.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.64,,,percent of total billed charges,,,82.96,,,percent of total billed charges,,,82.96,,,percent of total billed charges,,,,,,,,,,,,,,,82.96,,,percent of total billed charges,,,82.96,,,percent of total billed charges,,,,,,,,,82.96,,,fee schedule,,,77.17,,,percent of total billed charges,,,,,,,,,,,,,,,77.17,,,percent of total billed charges,,,77.17,,,percent of total billed charges,,,77.17,,,percent of total billed charges,,,62.22,,,percent of total billed charges,,,82.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,82.96,,,percent of total billed charges,,,82.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,58.25,,,percent of total billed charges,,
SUMATRIPTAN SUCC 100 MG TAB,2500017012,CDM,637,RC,6586214836,NDC,999,EAPG,,,,outpatient,facility,100,UN,82.96,82.96,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TACROLIMUS 0.5 MG CAP,2500017061,CDM,637,RC,J7507,HCPCS,904662361,NDC,,,,inpatient,facility,0.5,UN,3.46,3.46,0.28,3.46,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.11,,,percent of total billed charges,,,,,,,,,3.46,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,
TACROLIMUS 0.5 MG CAP,2500017061,CDM,637,RC,J7507,HCPCS,904662361,NDC,,,,outpatient,facility,0.5,UN,3.46,3.46,0.24,618.77,,2.02,,,percent of total billed charges,,,0.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.46,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.11,,,percent of total billed charges,,,,,,,,,3.46,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.63,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,3.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,,,,,,,3.46,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.24,,,fee schedule,,,3.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.46,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.43,,,percent of total billed charges,,
TACROLIMUS 0.5 MG CAP,2500017061,CDM,637,RC,J7507,HCPCS,904662361,NDC,496,EAPG,,outpatient,facility,0.5,UN,3.46,3.46,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TAMOXIFEN 10 MG TAB,2500017080,CDM,637,RC,378014491,NDC,,,,,,inpatient,facility,10,UN,6.23,6.23,0.5,6.23,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,6.23,,,percent of total billed charges,,,3.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,3.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,
TAMOXIFEN 10 MG TAB,2500017080,CDM,637,RC,378014491,NDC,,,,,,outpatient,facility,10,UN,6.23,6.23,0.5,618.77,,3.64,,,percent of total billed charges,,,1.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.23,,,percent of total billed charges,,,5.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.61,,,percent of total billed charges,,,,,,,,,6.23,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.25,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.73,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,6.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.5,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,6.23,,,fee schedule,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,6.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.37,,,percent of total billed charges,,
TAMOXIFEN 10 MG TAB,2500017080,CDM,637,RC,378014491,NDC,999,EAPG,,,,outpatient,facility,10,UN,6.23,6.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TAMSULOSIN HCL 0.4 MG CAP,2500017090,CDM,637,RC,904640161,NDC,,,,,,inpatient,facility,0.4,UN,1.45,1.45,0.12,1.45,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,
TAMSULOSIN HCL 0.4 MG CAP,2500017090,CDM,637,RC,904640161,NDC,,,,,,outpatient,facility,0.4,UN,1.45,1.45,0.12,618.77,,0.85,,,percent of total billed charges,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.45,,,percent of total billed charges,,,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.3,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.54,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,1.45,,,fee schedule,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.02,,,percent of total billed charges,,
TAMSULOSIN HCL 0.4 MG CAP,2500017090,CDM,637,RC,904640161,NDC,999,EAPG,,,,outpatient,facility,0.4,UN,1.45,1.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TETRAHYDROZOLINE 0.05  OP 15ML,2500017210,CDM,637,RC,5295959701,NDC,,,,,,inpatient,facility,15,UN,20.79,20.79,1.66,20.79,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,,,,,,,20.79,,,percent of total billed charges,,,11.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,10.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.6,,,percent of total billed charges,,
TETRAHYDROZOLINE 0.05  OP 15ML,2500017210,CDM,637,RC,5295959701,NDC,,,,,,outpatient,facility,15,UN,20.79,20.79,1.66,618.77,,12.14,,,percent of total billed charges,,,4.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,20.79,,,percent of total billed charges,,,18.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,18.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,18.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,18.71,,,percent of total billed charges,,,,,,,,,20.79,,,percent of total billed charges,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.97,,,percent of total billed charges,,,,,,,,,,,,,,,11.23,,,percent of total billed charges,,,11.23,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.84,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.8,,,percent of total billed charges,,,7.88,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.69,,,percent of total billed charges,,,7.69,,,percent of total billed charges,,,20.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.66,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,,,,,,,20.79,,,fee schedule,,,19.34,,,percent of total billed charges,,,,,,,,,,,,,,,19.34,,,percent of total billed charges,,,19.34,,,percent of total billed charges,,,19.34,,,percent of total billed charges,,,15.59,,,percent of total billed charges,,,20.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,20.79,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,14.6,,,percent of total billed charges,,
TETRAHYDROZOLINE 0.05  OP 15ML,2500017210,CDM,637,RC,5295959701,NDC,999,EAPG,,,,outpatient,facility,15,UN,20.79,20.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THEOPHYLLINE 400 MG CR TAB,2500017234,CDM,637,RC,6846238001,NDC,,,,,,inpatient,facility,400,UN,5.51,5.51,0.44,5.51,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,,,,,,,,5.51,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,
THEOPHYLLINE 400 MG CR TAB,2500017234,CDM,637,RC,6846238001,NDC,,,,,,outpatient,facility,400,UN,5.51,5.51,0.44,618.77,,3.22,,,percent of total billed charges,,,1.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.51,,,percent of total billed charges,,,4.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.96,,,percent of total billed charges,,,,,,,,,5.51,,,percent of total billed charges,,,3.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.23,,,percent of total billed charges,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,2.09,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,5.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.44,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,5.51,,,fee schedule,,,5.13,,,percent of total billed charges,,,,,,,,,,,,,,,5.13,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.87,,,percent of total billed charges,,
THEOPHYLLINE 400 MG CR TAB,2500017234,CDM,637,RC,6846238001,NDC,999,EAPG,,,,outpatient,facility,400,UN,5.51,5.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THEOPHYLLINE SR 300 MG TAB,2500017256,CDM,637,RC,6233202531,NDC,,,,,,inpatient,facility,300,UN,14.19,14.19,1.14,14.19,,,,,,,,,,,,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.77,,,percent of total billed charges,,,,,,,,,14.19,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,14.19,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.96,,,percent of total billed charges,,
THEOPHYLLINE SR 300 MG TAB,2500017256,CDM,637,RC,6233202531,NDC,,,,,,outpatient,facility,300,UN,14.19,14.19,1.14,618.77,,8.29,,,percent of total billed charges,,,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.19,,,percent of total billed charges,,,12.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.77,,,percent of total billed charges,,,,,,,,,14.19,,,percent of total billed charges,,,9.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.9,,,percent of total billed charges,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.4,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.78,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,7.35,,,percent of total billed charges,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.25,,,percent of total billed charges,,,5.25,,,percent of total billed charges,,,14.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.14,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,14.19,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,,,,,,,14.19,,,fee schedule,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,10.64,,,percent of total billed charges,,,14.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.19,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.96,,,percent of total billed charges,,
THEOPHYLLINE SR 300 MG TAB,2500017256,CDM,637,RC,6233202531,NDC,999,EAPG,,,,outpatient,facility,300,UN,14.19,14.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THIAMINE HCL 100 MG TAB,2500017273,CDM,637,RC,8068109800,NDC,,,,,,inpatient,facility,100,UN,1.92,1.92,0.15,1.92,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,,,,,,,1.92,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,
THIAMINE HCL 100 MG TAB,2500017273,CDM,637,RC,8068109800,NDC,,,,,,outpatient,facility,100,UN,1.92,1.92,0.15,618.77,,1.12,,,percent of total billed charges,,,0.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.92,,,percent of total billed charges,,,1.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.73,,,percent of total billed charges,,,,,,,,,1.92,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.46,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.71,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,1.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,1.92,,,fee schedule,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.79,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.35,,,percent of total billed charges,,
THIAMINE HCL 100 MG TAB,2500017273,CDM,637,RC,8068109800,NDC,999,EAPG,,,,outpatient,facility,100,UN,1.92,1.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THIAMINE HCL 100 MG/ML INJ,2500017274,CDM,636,RC,J3411,HCPCS,6332301302,NDC,,,,inpatient,facility,2,UN,32.83,32.83,2.63,32.83,,,,,,,,,,,,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.55,,,percent of total billed charges,,,,,,,,,32.83,,,percent of total billed charges,,,18.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,32.83,,,percent of total billed charges,,,17.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.63,,,percent of total billed charges,,,32.83,,,percent of total billed charges,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.05,,,percent of total billed charges,,
THIAMINE HCL 100 MG/ML INJ,2500017274,CDM,636,RC,J3411,HCPCS,6332301302,NDC,,,,outpatient,facility,2,UN,32.83,32.83,2.01,618.77,,19.17,,,percent of total billed charges,,,6.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,32.83,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,12.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,29.55,,,percent of total billed charges,,,,,,,,,32.83,,,percent of total billed charges,,,22.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.12,,,percent of total billed charges,,,32.83,,,percent of total billed charges,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.95,,,percent of total billed charges,,,12.44,,,percent of total billed charges,,,17,,,percent of total billed charges,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,32.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.63,,,percent of total billed charges,,,32.83,,,percent of total billed charges,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,32.83,,,percent of total billed charges,,,32.83,,,percent of total billed charges,,,,,,,,,32.83,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.01,,,fee schedule,,,32.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,32.83,,,percent of total billed charges,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,23.05,,,percent of total billed charges,,
THIAMINE HCL 100 MG/ML INJ,2500017274,CDM,636,RC,J3411,HCPCS,6332301302,NDC,496,EAPG,,outpatient,facility,2,UN,32.83,32.83,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THIOTHIXENE 5 MG CAP,2500017323,CDM,637,RC,5107958820,NDC,,,,,,inpatient,facility,5,UN,11.95,11.95,0.96,11.95,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.75,,,percent of total billed charges,,,,,,,,,11.95,,,percent of total billed charges,,,6.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.39,,,percent of total billed charges,,
THIOTHIXENE 5 MG CAP,2500017323,CDM,637,RC,5107958820,NDC,,,,,,outpatient,facility,5,UN,11.95,11.95,0.96,618.77,,6.98,,,percent of total billed charges,,,2.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.95,,,percent of total billed charges,,,10.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,10.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,10.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.75,,,percent of total billed charges,,,,,,,,,11.95,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.18,,,percent of total billed charges,,,,,,,,,,,,,,,6.45,,,percent of total billed charges,,,6.45,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.08,,,percent of total billed charges,,,4.53,,,percent of total billed charges,,,6.19,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,11.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.96,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,,,,,,,11.95,,,fee schedule,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,11.12,,,percent of total billed charges,,,11.12,,,percent of total billed charges,,,11.12,,,percent of total billed charges,,,8.96,,,percent of total billed charges,,,11.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.95,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.39,,,percent of total billed charges,,
THIOTHIXENE 5 MG CAP,2500017323,CDM,637,RC,5107958820,NDC,999,EAPG,,,,outpatient,facility,5,UN,11.95,11.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THROMBIN 5000 U INJ,2500017334,CDM,250,RC,6079321505,NDC,,,,,,inpatient,facility,5000,UN,238.03,238.03,19.04,238.03,,,,,,,,,,,,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.23,,,percent of total billed charges,,,,,,,,,238.03,,,percent of total billed charges,,,131.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,238.03,,,percent of total billed charges,,,124.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.14,,,percent of total billed charges,,
THROMBIN 5000 U INJ,2500017334,CDM,250,RC,6079321505,NDC,,,,,,outpatient,facility,5000,UN,238.03,238.03,19.04,618.77,,139.01,,,percent of total billed charges,,,46.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,238.03,,,percent of total billed charges,,,209.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,209.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,209.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,87.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,214.23,,,percent of total billed charges,,,,,,,,,238.03,,,percent of total billed charges,,,161.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,124.11,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.9,,,percent of total billed charges,,,90.17,,,percent of total billed charges,,,123.28,,,percent of total billed charges,,,,,,,,,,,,,,,47.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,95.21,,,percent of total billed charges,,,95.21,,,percent of total billed charges,,,238.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,238.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.04,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,238.03,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,,,,,,,238.03,,,fee schedule,,,95.21,,,percent of total billed charges,,,,,,,,,,,,,,,95.21,,,percent of total billed charges,,,95.21,,,percent of total billed charges,,,95.21,,,percent of total billed charges,,,178.52,,,percent of total billed charges,,,238.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,238.03,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,167.14,,,percent of total billed charges,,
THROMBIN 5000 U INJ,2500017334,CDM,250,RC,6079321505,NDC,999,EAPG,,,,outpatient,facility,5000,UN,238.03,238.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THROMBIN RECOMBINANT 5000 U,2500017335,CDM,250,RC,338032201,NDC,,,,,,inpatient,facility,5000,UN,283.8,283.8,22.7,283.8,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.42,,,percent of total billed charges,,,,,,,,,283.8,,,percent of total billed charges,,,157.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,147.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.28,,,percent of total billed charges,,
THROMBIN RECOMBINANT 5000 U,2500017335,CDM,250,RC,338032201,NDC,,,,,,outpatient,facility,5000,UN,283.8,283.8,22.7,618.77,,165.74,,,percent of total billed charges,,,55.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,283.8,,,percent of total billed charges,,,249.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,249.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,249.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,103.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,255.42,,,percent of total billed charges,,,,,,,,,283.8,,,percent of total billed charges,,,192.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,147.97,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.69,,,percent of total billed charges,,,107.5,,,percent of total billed charges,,,146.98,,,percent of total billed charges,,,,,,,,,,,,,,,56.76,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,113.52,,,percent of total billed charges,,,113.52,,,percent of total billed charges,,,283.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,283.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.7,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,,,,,,,283.8,,,fee schedule,,,113.52,,,percent of total billed charges,,,,,,,,,,,,,,,113.52,,,percent of total billed charges,,,113.52,,,percent of total billed charges,,,113.52,,,percent of total billed charges,,,212.85,,,percent of total billed charges,,,283.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,283.8,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,199.28,,,percent of total billed charges,,
THROMBIN RECOMBINANT 5000 U,2500017335,CDM,250,RC,338032201,NDC,999,EAPG,,,,outpatient,facility,5000,UN,283.8,283.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THYROID 30 MG TAB,2500017363,CDM,637,RC,456045801,NDC,,,,,,inpatient,facility,30,UN,3.17,3.17,0.25,3.17,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,
THYROID 30 MG TAB,2500017363,CDM,637,RC,456045801,NDC,,,,,,outpatient,facility,30,UN,3.17,3.17,0.25,618.77,,1.85,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.17,,,percent of total billed charges,,,2.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.85,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.17,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.25,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,3.17,,,fee schedule,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,2.95,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,3.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.23,,,percent of total billed charges,,
THYROID 30 MG TAB,2500017363,CDM,637,RC,456045801,NDC,999,EAPG,,,,outpatient,facility,30,UN,3.17,3.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIAGABINE HCL 4 MG TAB,2500017372,CDM,637,RC,6275622483,NDC,,,,,,inpatient,facility,4,UN,20.95,20.95,1.68,20.95,,,,,,,,,,,,,,20.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.86,,,percent of total billed charges,,,,,,,,,20.95,,,percent of total billed charges,,,11.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.95,,,percent of total billed charges,,,,,,,,,,,,,,,20.95,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,20.95,,,percent of total billed charges,,,20.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.71,,,percent of total billed charges,,
TIAGABINE HCL 4 MG TAB,2500017372,CDM,637,RC,6275622483,NDC,,,,,,outpatient,facility,4,UN,20.95,20.95,1.68,618.77,,12.23,,,percent of total billed charges,,,4.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,20.95,,,percent of total billed charges,,,18.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,18.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,18.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,20.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,18.86,,,percent of total billed charges,,,,,,,,,20.95,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.09,,,percent of total billed charges,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,20.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,20.95,,,percent of total billed charges,,,20.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.92,,,percent of total billed charges,,,7.94,,,percent of total billed charges,,,10.85,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.75,,,percent of total billed charges,,,7.75,,,percent of total billed charges,,,20.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.68,,,percent of total billed charges,,,20.95,,,percent of total billed charges,,,20.95,,,percent of total billed charges,,,,,,,,,,,,,,,20.95,,,percent of total billed charges,,,20.95,,,percent of total billed charges,,,,,,,,,20.95,,,fee schedule,,,19.49,,,percent of total billed charges,,,,,,,,,,,,,,,19.49,,,percent of total billed charges,,,19.49,,,percent of total billed charges,,,19.49,,,percent of total billed charges,,,15.71,,,percent of total billed charges,,,20.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,20.95,,,percent of total billed charges,,,20.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,14.71,,,percent of total billed charges,,
TIAGABINE HCL 4 MG TAB,2500017372,CDM,637,RC,6275622483,NDC,999,EAPG,,,,outpatient,facility,4,UN,20.95,20.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIMOLOL 0.25  OP SOLN 5 ML,2500017401,CDM,637,RC,6131422605,NDC,,,,,,inpatient,facility,5,UN,49.5,49.5,3.96,49.5,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.55,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,27.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,25.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.76,,,percent of total billed charges,,
TIMOLOL 0.25  OP SOLN 5 ML,2500017401,CDM,637,RC,6131422605,NDC,,,,,,outpatient,facility,5,UN,49.5,49.5,3.96,618.77,,28.91,,,percent of total billed charges,,,9.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,49.5,,,percent of total billed charges,,,43.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,43.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,43.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,18.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,44.55,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,33.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.02,,,percent of total billed charges,,,,,,,,,,,,,,,26.73,,,percent of total billed charges,,,26.73,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.81,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.62,,,percent of total billed charges,,,18.75,,,percent of total billed charges,,,25.64,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,18.32,,,percent of total billed charges,,,18.32,,,percent of total billed charges,,,49.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,49.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.96,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,49.5,,,fee schedule,,,46.04,,,percent of total billed charges,,,,,,,,,,,,,,,46.04,,,percent of total billed charges,,,46.04,,,percent of total billed charges,,,46.04,,,percent of total billed charges,,,37.13,,,percent of total billed charges,,,49.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,34.76,,,percent of total billed charges,,
TIMOLOL 0.25  OP SOLN 5 ML,2500017401,CDM,637,RC,6131422605,NDC,999,EAPG,,,,outpatient,facility,5,UN,49.5,49.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIMOLOL 0.5  OP SOLN 5 ML,2500017404,CDM,637,RC,6131422705,NDC,,,,,,inpatient,facility,5,UN,56.1,56.1,4.49,56.1,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.49,,,percent of total billed charges,,,,,,,,,56.1,,,percent of total billed charges,,,31.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,29.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.49,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.39,,,percent of total billed charges,,
TIMOLOL 0.5  OP SOLN 5 ML,2500017404,CDM,637,RC,6131422705,NDC,,,,,,outpatient,facility,5,UN,56.1,56.1,4.49,618.77,,32.76,,,percent of total billed charges,,,10.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,56.1,,,percent of total billed charges,,,49.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,49.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,49.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,20.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,50.49,,,percent of total billed charges,,,,,,,,,56.1,,,percent of total billed charges,,,37.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.08,,,percent of total billed charges,,,,,,,,,,,,,,,30.29,,,percent of total billed charges,,,30.29,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.25,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.64,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,29.05,,,percent of total billed charges,,,,,,,,,,,,,,,11.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,20.76,,,percent of total billed charges,,,20.76,,,percent of total billed charges,,,56.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,56.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.49,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,56.1,,,fee schedule,,,52.18,,,percent of total billed charges,,,,,,,,,,,,,,,52.18,,,percent of total billed charges,,,52.18,,,percent of total billed charges,,,52.18,,,percent of total billed charges,,,42.08,,,percent of total billed charges,,,56.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,56.1,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,39.39,,,percent of total billed charges,,
TIMOLOL 0.5  OP SOLN 5 ML,2500017404,CDM,637,RC,6131422705,NDC,999,EAPG,,,,outpatient,facility,5,UN,56.1,56.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIZANIDINE HCL 4 MG TAB,2500017420,CDM,637,RC,904641861,NDC,,,,,,inpatient,facility,4,UN,1.75,1.75,0.14,1.75,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,
TIZANIDINE HCL 4 MG TAB,2500017420,CDM,637,RC,904641861,NDC,,,,,,outpatient,facility,4,UN,1.75,1.75,0.14,618.77,,1.02,,,percent of total billed charges,,,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.75,,,percent of total billed charges,,,1.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.57,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.65,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,1.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.14,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,1.75,,,fee schedule,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,1.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.23,,,percent of total billed charges,,
TIZANIDINE HCL 4 MG TAB,2500017420,CDM,637,RC,904641861,NDC,999,EAPG,,,,outpatient,facility,4,UN,1.75,1.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TOBRAMYCIN 0.3  OP SOLN 5 ML,2500017441,CDM,637,RC,6233251805,NDC,,,,,,inpatient,facility,5,UN,112.13,112.13,8.97,112.13,,,,,,,,,,,,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.92,,,percent of total billed charges,,,,,,,,,112.13,,,percent of total billed charges,,,62.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,112.13,,,percent of total billed charges,,,58.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.97,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.74,,,percent of total billed charges,,
TOBRAMYCIN 0.3  OP SOLN 5 ML,2500017441,CDM,637,RC,6233251805,NDC,,,,,,outpatient,facility,5,UN,112.13,112.13,8.97,618.77,,65.48,,,percent of total billed charges,,,21.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,112.13,,,percent of total billed charges,,,98.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,98.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,98.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,41.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,100.92,,,percent of total billed charges,,,,,,,,,112.13,,,percent of total billed charges,,,75.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.12,,,percent of total billed charges,,,,,,,,,,,,,,,60.55,,,percent of total billed charges,,,60.55,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.46,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.22,,,percent of total billed charges,,,42.47,,,percent of total billed charges,,,58.07,,,percent of total billed charges,,,,,,,,,,,,,,,22.43,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,41.49,,,percent of total billed charges,,,41.49,,,percent of total billed charges,,,112.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,112.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.97,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,112.13,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,,,,,,,112.13,,,fee schedule,,,104.3,,,percent of total billed charges,,,,,,,,,,,,,,,104.3,,,percent of total billed charges,,,104.3,,,percent of total billed charges,,,104.3,,,percent of total billed charges,,,84.1,,,percent of total billed charges,,,112.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,112.13,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,78.74,,,percent of total billed charges,,
TOBRAMYCIN 0.3  OP SOLN 5 ML,2500017441,CDM,637,RC,6233251805,NDC,999,EAPG,,,,outpatient,facility,5,UN,112.13,112.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TOPIRAMATE 100 MG TAB,2500017530,CDM,637,RC,6808434401,NDC,,,,,,inpatient,facility,100,UN,20.46,20.46,1.64,20.46,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.41,,,percent of total billed charges,,,,,,,,,20.46,,,percent of total billed charges,,,11.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,10.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.37,,,percent of total billed charges,,
TOPIRAMATE 100 MG TAB,2500017530,CDM,637,RC,6808434401,NDC,,,,,,outpatient,facility,100,UN,20.46,20.46,1.64,618.77,,11.95,,,percent of total billed charges,,,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,20.46,,,percent of total billed charges,,,18.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,18.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,18.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,18.41,,,percent of total billed charges,,,,,,,,,20.46,,,percent of total billed charges,,,13.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.71,,,percent of total billed charges,,,,,,,,,,,,,,,11.05,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.67,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.55,,,percent of total billed charges,,,7.75,,,percent of total billed charges,,,10.6,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.57,,,percent of total billed charges,,,7.57,,,percent of total billed charges,,,20.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.64,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,,,,,,,20.46,,,fee schedule,,,19.03,,,percent of total billed charges,,,,,,,,,,,,,,,19.03,,,percent of total billed charges,,,19.03,,,percent of total billed charges,,,19.03,,,percent of total billed charges,,,15.35,,,percent of total billed charges,,,20.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,20.46,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,14.37,,,percent of total billed charges,,
TOPIRAMATE 100 MG TAB,2500017530,CDM,637,RC,6808434401,NDC,999,EAPG,,,,outpatient,facility,100,UN,20.46,20.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TOPIRAMATE 25 MG TAB,2500017533,CDM,637,RC,6808434201,NDC,,,,,,inpatient,facility,25,UN,6.93,6.93,0.55,6.93,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.24,,,percent of total billed charges,,,,,,,,,6.93,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,3.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.87,,,percent of total billed charges,,
TOPIRAMATE 25 MG TAB,2500017533,CDM,637,RC,6808434201,NDC,,,,,,outpatient,facility,25,UN,6.93,6.93,0.55,618.77,,4.05,,,percent of total billed charges,,,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.93,,,percent of total billed charges,,,6.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.24,,,percent of total billed charges,,,,,,,,,6.93,,,percent of total billed charges,,,4.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.32,,,percent of total billed charges,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,,3.74,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.61,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,2.63,,,percent of total billed charges,,,3.59,,,percent of total billed charges,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.56,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,6.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.55,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,6.93,,,fee schedule,,,6.45,,,percent of total billed charges,,,,,,,,,,,,,,,6.45,,,percent of total billed charges,,,6.45,,,percent of total billed charges,,,6.45,,,percent of total billed charges,,,5.2,,,percent of total billed charges,,,6.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.93,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.87,,,percent of total billed charges,,
TOPIRAMATE 25 MG TAB,2500017533,CDM,637,RC,6808434201,NDC,999,EAPG,,,,outpatient,facility,25,UN,6.93,6.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TORSEMIDE 10 MG TAB,2500017540,CDM,637,RC,3172253001,NDC,,,,,,inpatient,facility,10,UN,2.31,2.31,0.18,2.31,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,
TORSEMIDE 10 MG TAB,2500017540,CDM,637,RC,3172253001,NDC,,,,,,outpatient,facility,10,UN,2.31,2.31,0.18,618.77,,1.35,,,percent of total billed charges,,,0.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.31,,,percent of total billed charges,,,2.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.08,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.85,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,2.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,2.31,,,fee schedule,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,2.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.62,,,percent of total billed charges,,
TORSEMIDE 10 MG TAB,2500017540,CDM,637,RC,3172253001,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.31,2.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TORSEMIDE 20 MG TAB,2500017541,CDM,637,RC,5026875615,NDC,,,,,,inpatient,facility,20,UN,2.74,2.74,0.22,2.74,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,,,,,,,2.74,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,
TORSEMIDE 20 MG TAB,2500017541,CDM,637,RC,5026875615,NDC,,,,,,outpatient,facility,20,UN,2.74,2.74,0.22,618.77,,1.6,,,percent of total billed charges,,,0.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.74,,,percent of total billed charges,,,2.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.47,,,percent of total billed charges,,,,,,,,,2.74,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,2.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.22,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,2.74,,,fee schedule,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,2.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.74,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.92,,,percent of total billed charges,,
TORSEMIDE 20 MG TAB,2500017541,CDM,637,RC,5026875615,NDC,999,EAPG,,,,outpatient,facility,20,UN,2.74,2.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TPN/PPN ADULT,2500017564,CDM,250,RC,338113703,NDC,,,,,,inpatient,facility,3000,UN,198,198,15.84,198,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,,,,,,,198,,,percent of total billed charges,,,109.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,103.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.04,,,percent of total billed charges,,
TPN/PPN ADULT,2500017564,CDM,250,RC,338113703,NDC,,,,,,outpatient,facility,3000,UN,198,198,15.84,618.77,,115.63,,,percent of total billed charges,,,38.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,198,,,percent of total billed charges,,,174.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,174.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,174.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,72.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,178.2,,,percent of total billed charges,,,,,,,,,198,,,percent of total billed charges,,,134.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.24,,,percent of total billed charges,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.48,,,percent of total billed charges,,,75,,,percent of total billed charges,,,102.54,,,percent of total billed charges,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,79.2,,,percent of total billed charges,,,79.2,,,percent of total billed charges,,,198,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,198,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.84,,,percent of total billed charges,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,198,,,fee schedule,,,79.2,,,percent of total billed charges,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,79.2,,,percent of total billed charges,,,79.2,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,198,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,139.04,,,percent of total billed charges,,
TPN/PPN ADULT,2500017564,CDM,250,RC,338113703,NDC,999,EAPG,,,,outpatient,facility,3000,UN,198,198,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRACE ELEMENTS 1 ML INJ,2500017570,CDM,250,RC,517930525,NDC,,,,,,inpatient,facility,1,UN,85.21,85.21,6.82,85.21,,,,,,,,,,,,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.69,,,percent of total billed charges,,,,,,,,,85.21,,,percent of total billed charges,,,47.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,85.21,,,percent of total billed charges,,,44.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.82,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.83,,,percent of total billed charges,,
TRACE ELEMENTS 1 ML INJ,2500017570,CDM,250,RC,517930525,NDC,,,,,,outpatient,facility,1,UN,85.21,85.21,6.82,618.77,,49.76,,,percent of total billed charges,,,16.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,85.21,,,percent of total billed charges,,,75.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,75.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,75.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,31.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,76.69,,,percent of total billed charges,,,,,,,,,85.21,,,percent of total billed charges,,,57.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,44.43,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.76,,,percent of total billed charges,,,32.28,,,percent of total billed charges,,,44.13,,,percent of total billed charges,,,,,,,,,,,,,,,17.04,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,34.08,,,percent of total billed charges,,,34.08,,,percent of total billed charges,,,85.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,85.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.82,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,85.21,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,,,,,,,85.21,,,fee schedule,,,34.08,,,percent of total billed charges,,,,,,,,,,,,,,,34.08,,,percent of total billed charges,,,34.08,,,percent of total billed charges,,,34.08,,,percent of total billed charges,,,63.91,,,percent of total billed charges,,,85.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,85.21,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,59.83,,,percent of total billed charges,,
TRACE ELEMENTS 1 ML INJ,2500017570,CDM,250,RC,517930525,NDC,999,EAPG,,,,outpatient,facility,1,UN,85.21,85.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAMADOL 50 MG TAB,2500017580,CDM,637,RC,904717961,NDC,,,,,,inpatient,facility,50,UN,0.49,0.49,0.04,0.49,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,
TRAMADOL 50 MG TAB,2500017580,CDM,637,RC,904717961,NDC,,,,,,outpatient,facility,50,UN,0.49,0.49,0.04,618.77,,0.29,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.49,,,percent of total billed charges,,,0.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.44,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.18,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,0.49,,,fee schedule,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,0.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.34,,,percent of total billed charges,,
TRAMADOL 50 MG TAB,2500017580,CDM,637,RC,904717961,NDC,999,EAPG,,,,outpatient,facility,50,UN,0.49,0.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAZODONE HCL 100 MG TAB,2500017600,CDM,637,RC,904686961,NDC,,,,,,inpatient,facility,100,UN,0.59,0.59,0.05,0.59,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,
TRAZODONE HCL 100 MG TAB,2500017600,CDM,637,RC,904686961,NDC,,,,,,outpatient,facility,100,UN,0.59,0.59,0.05,618.77,,0.34,,,percent of total billed charges,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,0.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.53,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.22,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,0.59,,,fee schedule,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,0.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.41,,,percent of total billed charges,,
TRAZODONE HCL 100 MG TAB,2500017600,CDM,637,RC,904686961,NDC,999,EAPG,,,,outpatient,facility,100,UN,0.59,0.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAZODONE HCL 50 MG TAB,2500017601,CDM,637,RC,904686861,NDC,,,,,,inpatient,facility,50,UN,0.39,0.39,0.03,0.39,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,
TRAZODONE HCL 50 MG TAB,2500017601,CDM,637,RC,904686861,NDC,,,,,,outpatient,facility,50,UN,0.39,0.39,0.03,618.77,,0.23,,,percent of total billed charges,,,0.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.39,,,percent of total billed charges,,,0.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.35,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.14,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,0.39,,,fee schedule,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.27,,,percent of total billed charges,,
TRAZODONE HCL 50 MG TAB,2500017601,CDM,637,RC,904686861,NDC,999,EAPG,,,,outpatient,facility,50,UN,0.39,0.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIAMCINOLONE 0.1  CR 15 GM,2500017624,CDM,637,RC,6787725115,NDC,,,,,,inpatient,facility,15,UN,19.24,19.24,1.54,19.24,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.32,,,percent of total billed charges,,,,,,,,,19.24,,,percent of total billed charges,,,10.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.51,,,percent of total billed charges,,
TRIAMCINOLONE 0.1  CR 15 GM,2500017624,CDM,637,RC,6787725115,NDC,,,,,,outpatient,facility,15,UN,19.24,19.24,1.54,618.77,,11.24,,,percent of total billed charges,,,3.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,19.24,,,percent of total billed charges,,,16.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,16.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,16.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,17.32,,,percent of total billed charges,,,,,,,,,19.24,,,percent of total billed charges,,,13.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.78,,,percent of total billed charges,,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.62,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,9.96,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.12,,,percent of total billed charges,,,7.12,,,percent of total billed charges,,,19.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.54,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,,,,,,,19.24,,,fee schedule,,,17.9,,,percent of total billed charges,,,,,,,,,,,,,,,17.9,,,percent of total billed charges,,,17.9,,,percent of total billed charges,,,17.9,,,percent of total billed charges,,,14.43,,,percent of total billed charges,,,19.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.62,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,13.51,,,percent of total billed charges,,
TRIAMCINOLONE 0.1  CR 15 GM,2500017624,CDM,637,RC,6787725115,NDC,999,EAPG,,,,outpatient,facility,15,UN,19.24,19.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIAMCINOLONE 0.1  ORABAS 5GM,2500017626,CDM,637,RC,713065540,NDC,,,,,,inpatient,facility,5,UN,274,274,21.92,274,,,,,,,,,,,,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.6,,,percent of total billed charges,,,,,,,,,274,,,percent of total billed charges,,,151.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,274,,,percent of total billed charges,,,142.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.92,,,percent of total billed charges,,,274,,,percent of total billed charges,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.4,,,percent of total billed charges,,
TRIAMCINOLONE 0.1  ORABAS 5GM,2500017626,CDM,637,RC,713065540,NDC,,,,,,outpatient,facility,5,UN,274,274,21.92,618.77,,160.02,,,percent of total billed charges,,,53.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,274,,,percent of total billed charges,,,241.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,241.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,241.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,100.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,246.6,,,percent of total billed charges,,,,,,,,,274,,,percent of total billed charges,,,185.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210.43,,,percent of total billed charges,,,,,,,,,,,,,,,147.96,,,percent of total billed charges,,,147.96,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.86,,,percent of total billed charges,,,274,,,percent of total billed charges,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,208.24,,,percent of total billed charges,,,103.79,,,percent of total billed charges,,,141.9,,,percent of total billed charges,,,,,,,,,,,,,,,54.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,101.38,,,percent of total billed charges,,,101.38,,,percent of total billed charges,,,274,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,274,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.92,,,percent of total billed charges,,,274,,,percent of total billed charges,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,274,,,percent of total billed charges,,,274,,,percent of total billed charges,,,,,,,,,274,,,fee schedule,,,254.87,,,percent of total billed charges,,,,,,,,,,,,,,,254.87,,,percent of total billed charges,,,254.87,,,percent of total billed charges,,,254.87,,,percent of total billed charges,,,205.5,,,percent of total billed charges,,,274,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,274,,,percent of total billed charges,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,192.4,,,percent of total billed charges,,
TRIAMCINOLONE 0.1  ORABAS 5GM,2500017626,CDM,637,RC,713065540,NDC,999,EAPG,,,,outpatient,facility,5,UN,274,274,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIAMCINOLONE 0.1  OINT 15GM,2500017627,CDM,637,RC,3334233315,NDC,,,,,,inpatient,facility,15,UN,18.38,18.38,1.47,18.38,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.54,,,percent of total billed charges,,,,,,,,,18.38,,,percent of total billed charges,,,10.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,9.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.91,,,percent of total billed charges,,
TRIAMCINOLONE 0.1  OINT 15GM,2500017627,CDM,637,RC,3334233315,NDC,,,,,,outpatient,facility,15,UN,18.38,18.38,1.47,618.77,,10.73,,,percent of total billed charges,,,3.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,18.38,,,percent of total billed charges,,,16.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,16.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,16.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,16.54,,,percent of total billed charges,,,,,,,,,18.38,,,percent of total billed charges,,,12.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.58,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.97,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,9.52,,,percent of total billed charges,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.8,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,18.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.47,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,,,,,,,18.38,,,fee schedule,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,17.1,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,13.79,,,percent of total billed charges,,,18.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,18.38,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,12.91,,,percent of total billed charges,,
TRIAMCINOLONE 0.1  OINT 15GM,2500017627,CDM,637,RC,3334233315,NDC,999,EAPG,,,,outpatient,facility,15,UN,18.38,18.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIAMTERENE/HCTZ 37.5-25MG TAB,2500017651,CDM,637,RC,6050526561,NDC,,,,,,inpatient,facility,1,UN,1.29,1.29,0.1,1.29,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,
TRIAMTERENE/HCTZ 37.5-25MG TAB,2500017651,CDM,637,RC,6050526561,NDC,,,,,,outpatient,facility,1,UN,1.29,1.29,0.1,618.77,,0.75,,,percent of total billed charges,,,0.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.29,,,percent of total billed charges,,,1.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.16,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.48,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,1.29,,,fee schedule,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,1.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.91,,,percent of total billed charges,,
TRIAMTERENE/HCTZ 37.5-25MG TAB,2500017651,CDM,637,RC,6050526561,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.29,1.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIHEXYPHENIDYL 2 MG TAB,2500017734,CDM,637,RC,591533501,NDC,,,,,,inpatient,facility,2,UN,0.59,0.59,0.05,0.59,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,
TRIHEXYPHENIDYL 2 MG TAB,2500017734,CDM,637,RC,591533501,NDC,,,,,,outpatient,facility,2,UN,0.59,0.59,0.05,618.77,,0.34,,,percent of total billed charges,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,0.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.53,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.22,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,0.59,,,fee schedule,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,0.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.41,,,percent of total billed charges,,
TRIHEXYPHENIDYL 2 MG TAB,2500017734,CDM,637,RC,591533501,NDC,999,EAPG,,,,outpatient,facility,2,UN,0.59,0.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIHEXYPHENIDYL 5 MG TAB,2500017735,CDM,637,RC,591533701,NDC,,,,,,inpatient,facility,5,UN,1.19,1.19,0.1,1.19,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,
TRIHEXYPHENIDYL 5 MG TAB,2500017735,CDM,637,RC,591533701,NDC,,,,,,outpatient,facility,5,UN,1.19,1.19,0.1,618.77,,0.69,,,percent of total billed charges,,,0.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.19,,,percent of total billed charges,,,1.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.07,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.44,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,1.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,1.19,,,fee schedule,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,1.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.84,,,percent of total billed charges,,
TRIHEXYPHENIDYL 5 MG TAB,2500017735,CDM,637,RC,591533701,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.19,1.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIMETHOPRIM/SULFAMETH 20 ML,2500017792,CDM,637,RC,121085340,NDC,,,,,,inpatient,facility,20,UN,59.07,59.07,4.73,59.07,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.16,,,percent of total billed charges,,,,,,,,,59.07,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,,30.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.73,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.48,,,percent of total billed charges,,
TRIMETHOPRIM/SULFAMETH 20 ML,2500017792,CDM,637,RC,121085340,NDC,,,,,,outpatient,facility,20,UN,59.07,59.07,4.73,618.77,,34.5,,,percent of total billed charges,,,11.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,59.07,,,percent of total billed charges,,,52.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,52.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,52.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,21.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,53.16,,,percent of total billed charges,,,,,,,,,59.07,,,percent of total billed charges,,,40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.37,,,percent of total billed charges,,,,,,,,,,,,,,,31.9,,,percent of total billed charges,,,31.9,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.8,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.89,,,percent of total billed charges,,,22.38,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,11.81,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,21.86,,,percent of total billed charges,,,21.86,,,percent of total billed charges,,,59.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,59.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.73,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,,,,,,,59.07,,,fee schedule,,,54.95,,,percent of total billed charges,,,,,,,,,,,,,,,54.95,,,percent of total billed charges,,,54.95,,,percent of total billed charges,,,54.95,,,percent of total billed charges,,,44.3,,,percent of total billed charges,,,59.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,59.07,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,41.48,,,percent of total billed charges,,
TRIMETHOPRIM/SULFAMETH 20 ML,2500017792,CDM,637,RC,121085340,NDC,999,EAPG,,,,outpatient,facility,20,UN,59.07,59.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TROPICAMIDE 1  OP SOLN 3 ML,2500017863,CDM,637,RC,6131435501,NDC,,,,,,inpatient,facility,3,UN,46.2,46.2,3.7,46.2,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.58,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,25.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,24.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.44,,,percent of total billed charges,,
TROPICAMIDE 1  OP SOLN 3 ML,2500017863,CDM,637,RC,6131435501,NDC,,,,,,outpatient,facility,3,UN,46.2,46.2,3.7,618.77,,26.98,,,percent of total billed charges,,,9.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,46.2,,,percent of total billed charges,,,40.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,40.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,40.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,41.58,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,31.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.48,,,percent of total billed charges,,,,,,,,,,,,,,,24.95,,,percent of total billed charges,,,24.95,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.09,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.11,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,17.09,,,percent of total billed charges,,,17.09,,,percent of total billed charges,,,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,46.2,,,fee schedule,,,42.98,,,percent of total billed charges,,,,,,,,,,,,,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,46.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,32.44,,,percent of total billed charges,,
TROPICAMIDE 1  OP SOLN 3 ML,2500017863,CDM,637,RC,6131435501,NDC,999,EAPG,,,,outpatient,facility,3,UN,46.2,46.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TUBERCULIN PPD 5 TU/0.1 ML 1ML,2500017893,CDM,250,RC,4928175221,NDC,,,,,,inpatient,facility,0.1,UN,31.78,31.78,2.54,31.78,,,,,,,,,,,,,,31.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.6,,,percent of total billed charges,,,,,,,,,31.78,,,percent of total billed charges,,,17.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.78,,,percent of total billed charges,,,,,,,,,,,,,,,31.78,,,percent of total billed charges,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,31.78,,,percent of total billed charges,,,31.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.32,,,percent of total billed charges,,
TUBERCULIN PPD 5 TU/0.1 ML 1ML,2500017893,CDM,250,RC,4928175221,NDC,,,,,,outpatient,facility,0.1,UN,31.78,31.78,2.54,618.77,,18.56,,,percent of total billed charges,,,6.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,31.78,,,percent of total billed charges,,,27.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,27.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,27.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,31.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,28.6,,,percent of total billed charges,,,,,,,,,31.78,,,percent of total billed charges,,,21.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,31.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,31.78,,,percent of total billed charges,,,31.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.15,,,percent of total billed charges,,,12.04,,,percent of total billed charges,,,16.46,,,percent of total billed charges,,,,,,,,,,,,,,,6.36,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,12.71,,,percent of total billed charges,,,12.71,,,percent of total billed charges,,,31.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.54,,,percent of total billed charges,,,31.78,,,percent of total billed charges,,,31.78,,,percent of total billed charges,,,,,,,,,,,,,,,31.78,,,percent of total billed charges,,,31.78,,,percent of total billed charges,,,,,,,,,31.78,,,fee schedule,,,12.71,,,percent of total billed charges,,,,,,,,,,,,,,,12.71,,,percent of total billed charges,,,12.71,,,percent of total billed charges,,,12.71,,,percent of total billed charges,,,23.84,,,percent of total billed charges,,,31.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,31.78,,,percent of total billed charges,,,31.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,22.32,,,percent of total billed charges,,
TUBERCULIN PPD 5 TU/0.1 ML 1ML,2500017893,CDM,250,RC,4928175221,NDC,999,EAPG,,,,outpatient,facility,0.1,UN,31.78,31.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
URSODIOL 300 MG CAP,2500017983,CDM,637,RC,6923815401,NDC,,,,,,inpatient,facility,300,UN,24.25,24.25,1.94,24.25,,,,,,,,,,,,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.82,,,percent of total billed charges,,,,,,,,,24.25,,,percent of total billed charges,,,13.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,24.25,,,percent of total billed charges,,,12.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.03,,,percent of total billed charges,,
URSODIOL 300 MG CAP,2500017983,CDM,637,RC,6923815401,NDC,,,,,,outpatient,facility,300,UN,24.25,24.25,1.94,618.77,,14.16,,,percent of total billed charges,,,4.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,24.25,,,percent of total billed charges,,,21.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,21.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,21.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,21.82,,,percent of total billed charges,,,,,,,,,24.25,,,percent of total billed charges,,,16.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.62,,,percent of total billed charges,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.64,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.43,,,percent of total billed charges,,,9.19,,,percent of total billed charges,,,12.56,,,percent of total billed charges,,,,,,,,,,,,,,,4.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.97,,,percent of total billed charges,,,8.97,,,percent of total billed charges,,,24.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.94,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,24.25,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,,,,,,,24.25,,,fee schedule,,,22.56,,,percent of total billed charges,,,,,,,,,,,,,,,22.56,,,percent of total billed charges,,,22.56,,,percent of total billed charges,,,22.56,,,percent of total billed charges,,,18.19,,,percent of total billed charges,,,24.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,24.25,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.03,,,percent of total billed charges,,
URSODIOL 300 MG CAP,2500017983,CDM,637,RC,6923815401,NDC,999,EAPG,,,,outpatient,facility,300,UN,24.25,24.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALACYCLOVIR HCL 500 MG TAB,2500017990,CDM,637,RC,904656561,NDC,,,,,,inpatient,facility,500,UN,8.05,8.05,0.64,8.05,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,,,,,,,8.05,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,4.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.65,,,percent of total billed charges,,
VALACYCLOVIR HCL 500 MG TAB,2500017990,CDM,637,RC,904656561,NDC,,,,,,outpatient,facility,500,UN,8.05,8.05,0.64,618.77,,4.7,,,percent of total billed charges,,,1.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.05,,,percent of total billed charges,,,7.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.25,,,percent of total billed charges,,,,,,,,,8.05,,,percent of total billed charges,,,5.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.18,,,percent of total billed charges,,,,,,,,,,,,,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.2,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,4.17,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.98,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,8.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.64,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,8.05,,,fee schedule,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,6.04,,,percent of total billed charges,,,8.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.05,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.65,,,percent of total billed charges,,
VALACYCLOVIR HCL 500 MG TAB,2500017990,CDM,637,RC,904656561,NDC,999,EAPG,,,,outpatient,facility,500,UN,8.05,8.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALPROATE SOD 100MG/ML 5ML INJ,2500018000,CDM,250,RC,J3490,HCPCS,6332349405,NDC,,,,inpatient,facility,5,UN,22.11,22.11,1.77,22.11,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.9,,,percent of total billed charges,,,,,,,,,22.11,,,percent of total billed charges,,,12.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,11.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.53,,,percent of total billed charges,,
VALPROATE SOD 100MG/ML 5ML INJ,2500018000,CDM,250,RC,J3490,HCPCS,6332349405,NDC,,,,outpatient,facility,5,UN,22.11,22.11,1.2,618.77,,12.91,,,percent of total billed charges,,,4.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,22.11,,,percent of total billed charges,,,19.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,19.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,19.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,19.9,,,percent of total billed charges,,,,,,,,,22.11,,,percent of total billed charges,,,14.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.98,,,percent of total billed charges,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.53,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.8,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,22.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.77,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,22.11,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,16.58,,,percent of total billed charges,,,22.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,15.53,,,percent of total billed charges,,
VALPROATE SOD 100MG/ML 5ML INJ,2500018000,CDM,250,RC,J3490,HCPCS,6332349405,NDC,435,EAPG,,outpatient,facility,5,UN,22.11,22.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALPROIC ACID 250MG/5ML  UDC,2500018014,CDM,637,RC,121467500,NDC,,,,,,inpatient,facility,5,UN,4.95,4.95,0.4,4.95,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,4.95,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,
VALPROIC ACID 250MG/5ML  UDC,2500018014,CDM,637,RC,121467500,NDC,,,,,,outpatient,facility,5,UN,4.95,4.95,0.4,618.77,,2.89,,,percent of total billed charges,,,0.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.95,,,percent of total billed charges,,,4.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.46,,,percent of total billed charges,,,,,,,,,4.95,,,percent of total billed charges,,,3.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.83,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,4.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.4,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,4.95,,,fee schedule,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,4.6,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,4.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.48,,,percent of total billed charges,,
VALPROIC ACID 250MG/5ML  UDC,2500018014,CDM,637,RC,121467500,NDC,999,EAPG,,,,outpatient,facility,5,UN,4.95,4.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 125 MG CAP,2500018030,CDM,637,RC,121086720,NDC,,,,,,inpatient,facility,125,UN,103.32,103.32,8.27,103.32,,,,,,,,,,,,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.99,,,percent of total billed charges,,,,,,,,,103.32,,,percent of total billed charges,,,57.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,103.32,,,percent of total billed charges,,,53.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.27,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.55,,,percent of total billed charges,,
VANCOMYCIN 125 MG CAP,2500018030,CDM,637,RC,121086720,NDC,,,,,,outpatient,facility,125,UN,103.32,103.32,8.27,618.77,,60.34,,,percent of total billed charges,,,20.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,103.32,,,percent of total billed charges,,,90.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,90.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,90.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,37.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,92.99,,,percent of total billed charges,,,,,,,,,103.32,,,percent of total billed charges,,,69.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.35,,,percent of total billed charges,,,,,,,,,,,,,,,55.79,,,percent of total billed charges,,,55.79,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.87,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.52,,,percent of total billed charges,,,39.14,,,percent of total billed charges,,,53.51,,,percent of total billed charges,,,,,,,,,,,,,,,20.66,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,38.23,,,percent of total billed charges,,,38.23,,,percent of total billed charges,,,103.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.27,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,103.32,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,,,,,,,103.32,,,fee schedule,,,96.11,,,percent of total billed charges,,,,,,,,,,,,,,,96.11,,,percent of total billed charges,,,96.11,,,percent of total billed charges,,,96.11,,,percent of total billed charges,,,77.49,,,percent of total billed charges,,,103.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,103.32,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,72.55,,,percent of total billed charges,,
VANCOMYCIN 125 MG CAP,2500018030,CDM,637,RC,121086720,NDC,999,EAPG,,,,outpatient,facility,125,UN,103.32,103.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 250 MG CAP,2500018031,CDM,637,RC,121089020,NDC,,,,,,inpatient,facility,250,UN,190.48,190.48,15.24,190.48,,,,,,,,,,,,,,190.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.43,,,percent of total billed charges,,,,,,,,,190.48,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.48,,,percent of total billed charges,,,,,,,,,,,,,,,190.48,,,percent of total billed charges,,,99.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.24,,,percent of total billed charges,,,190.48,,,percent of total billed charges,,,190.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,190.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.76,,,percent of total billed charges,,
VANCOMYCIN 250 MG CAP,2500018031,CDM,637,RC,121089020,NDC,,,,,,outpatient,facility,250,UN,190.48,190.48,15.24,618.77,,111.24,,,percent of total billed charges,,,37.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,190.48,,,percent of total billed charges,,,167.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,167.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,167.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,190.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,69.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,171.43,,,percent of total billed charges,,,,,,,,,190.48,,,percent of total billed charges,,,128.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.29,,,percent of total billed charges,,,,,,,,,,,,,,,102.86,,,percent of total billed charges,,,102.86,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,190.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,99.32,,,percent of total billed charges,,,190.48,,,percent of total billed charges,,,190.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.76,,,percent of total billed charges,,,72.15,,,percent of total billed charges,,,98.65,,,percent of total billed charges,,,,,,,,,,,,,,,38.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,70.48,,,percent of total billed charges,,,70.48,,,percent of total billed charges,,,190.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,190.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.24,,,percent of total billed charges,,,190.48,,,percent of total billed charges,,,190.48,,,percent of total billed charges,,,,,,,,,,,,,,,190.48,,,percent of total billed charges,,,190.48,,,percent of total billed charges,,,,,,,,,190.48,,,fee schedule,,,177.18,,,percent of total billed charges,,,,,,,,,,,,,,,177.18,,,percent of total billed charges,,,177.18,,,percent of total billed charges,,,177.18,,,percent of total billed charges,,,142.86,,,percent of total billed charges,,,190.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,190.48,,,percent of total billed charges,,,190.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,133.76,,,percent of total billed charges,,
VANCOMYCIN 250 MG CAP,2500018031,CDM,637,RC,121089020,NDC,999,EAPG,,,,outpatient,facility,250,UN,190.48,190.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 125 MG/2.5 ML PFOS,2500018033,CDM,637,RC,6745733950,NDC,,,,,,inpatient,facility,2.5,UN,31.84,31.84,2.55,31.84,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.66,,,percent of total billed charges,,,,,,,,,31.84,,,percent of total billed charges,,,17.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.36,,,percent of total billed charges,,
VANCOMYCIN 125 MG/2.5 ML PFOS,2500018033,CDM,637,RC,6745733950,NDC,,,,,,outpatient,facility,2.5,UN,31.84,31.84,2.55,618.77,,18.59,,,percent of total billed charges,,,6.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,31.84,,,percent of total billed charges,,,28.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,28.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,28.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,28.66,,,percent of total billed charges,,,,,,,,,31.84,,,percent of total billed charges,,,21.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.2,,,percent of total billed charges,,,12.06,,,percent of total billed charges,,,16.49,,,percent of total billed charges,,,,,,,,,,,,,,,6.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,11.78,,,percent of total billed charges,,,11.78,,,percent of total billed charges,,,31.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.55,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,,,,,,,31.84,,,fee schedule,,,29.62,,,percent of total billed charges,,,,,,,,,,,,,,,29.62,,,percent of total billed charges,,,29.62,,,percent of total billed charges,,,29.62,,,percent of total billed charges,,,23.88,,,percent of total billed charges,,,31.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,31.84,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,22.36,,,percent of total billed charges,,
VANCOMYCIN 125 MG/2.5 ML PFOS,2500018033,CDM,637,RC,6745733950,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,31.84,31.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VASOPRESSIN 20 U/ML INJ,2500018060,CDM,636,RC,J2599,HCPCS,4202316425,NDC,,,,inpatient,facility,1,UN,651.95,651.95,52.16,651.95,,,,,,,,,,,,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,586.76,,,percent of total billed charges,,,,,,,,,651.95,,,percent of total billed charges,,,360.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,594.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,651.95,,,percent of total billed charges,,,339.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.16,,,percent of total billed charges,,,651.95,,,percent of total billed charges,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,457.8,,,percent of total billed charges,,
VASOPRESSIN 20 U/ML INJ,2500018060,CDM,636,RC,J2599,HCPCS,4202316425,NDC,,,,outpatient,facility,1,UN,651.95,651.95,1.63,651.95,,380.74,,,percent of total billed charges,,,127.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,651.95,,,percent of total billed charges,,,1.86,,,fee schedule,,,1.79,,,fee schedule,,,,,,,,,1.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,238.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,586.76,,,percent of total billed charges,,,,,,,,,651.95,,,percent of total billed charges,,,441.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,339.93,,,percent of total billed charges,,,651.95,,,percent of total billed charges,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495.48,,,percent of total billed charges,,,246.96,,,percent of total billed charges,,,337.64,,,percent of total billed charges,,,,,,,,,,,,,,,130.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,651.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,651.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,52.16,,,percent of total billed charges,,,651.95,,,percent of total billed charges,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,651.95,,,percent of total billed charges,,,651.95,,,percent of total billed charges,,,,,,,,,651.95,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.63,,,fee schedule,,,651.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,651.95,,,percent of total billed charges,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,457.8,,,percent of total billed charges,,
VASOPRESSIN 20 U/ML INJ,2500018060,CDM,636,RC,J2599,HCPCS,4202316425,NDC,999,EAPG,,outpatient,facility,1,UN,651.95,651.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VECURONIUM BR 10 MG/10 ML INJ,2500018070,CDM,250,RC,J3490,HCPCS,4733593144,NDC,,,,inpatient,facility,10,UN,28.05,28.05,2.24,28.05,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.25,,,percent of total billed charges,,,,,,,,,28.05,,,percent of total billed charges,,,15.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,14.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.7,,,percent of total billed charges,,
VECURONIUM BR 10 MG/10 ML INJ,2500018070,CDM,250,RC,J3490,HCPCS,4733593144,NDC,,,,outpatient,facility,10,UN,28.05,28.05,1.2,618.77,,16.38,,,percent of total billed charges,,,5.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,28.05,,,percent of total billed charges,,,24.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,24.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,24.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,25.25,,,percent of total billed charges,,,,,,,,,28.05,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.54,,,percent of total billed charges,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.63,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.32,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,14.53,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,28.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.24,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,28.05,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,21.04,,,percent of total billed charges,,,28.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,19.7,,,percent of total billed charges,,
VECURONIUM BR 10 MG/10 ML INJ,2500018070,CDM,250,RC,J3490,HCPCS,4733593144,NDC,435,EAPG,,outpatient,facility,10,UN,28.05,28.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VECURONIUM BR 20 MG/20 ML INJ,2500018071,CDM,250,RC,J3490,HCPCS,5515023620,NDC,,,,inpatient,facility,20,UN,44.55,44.55,3.56,44.55,,,,,,,,,,,,,,44.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.09,,,percent of total billed charges,,,,,,,,,44.55,,,percent of total billed charges,,,24.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.55,,,percent of total billed charges,,,,,,,,,,,,,,,44.55,,,percent of total billed charges,,,23.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,44.55,,,percent of total billed charges,,,44.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,44.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,
VECURONIUM BR 20 MG/20 ML INJ,2500018071,CDM,250,RC,J3490,HCPCS,5515023620,NDC,,,,outpatient,facility,20,UN,44.55,44.55,1.2,618.77,,26.02,,,percent of total billed charges,,,8.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,44.55,,,percent of total billed charges,,,39.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,39.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,39.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,44.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,40.09,,,percent of total billed charges,,,,,,,,,44.55,,,percent of total billed charges,,,30.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.21,,,percent of total billed charges,,,,,,,,,,,,,,,44.55,,,percent of total billed charges,,,44.55,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,44.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.23,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.86,,,percent of total billed charges,,,16.88,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,44.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,44.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.56,,,percent of total billed charges,,,44.55,,,percent of total billed charges,,,44.55,,,percent of total billed charges,,,,,,,,,,,,,,,44.55,,,percent of total billed charges,,,44.55,,,percent of total billed charges,,,,,,,,,44.55,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,33.41,,,percent of total billed charges,,,44.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,44.55,,,percent of total billed charges,,,44.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,31.28,,,percent of total billed charges,,
VECURONIUM BR 20 MG/20 ML INJ,2500018071,CDM,250,RC,J3490,HCPCS,5515023620,NDC,435,EAPG,,outpatient,facility,20,UN,44.55,44.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VENLAFAXINE HCL 25 MG TAB,2500018081,CDM,637,RC,5140745390,NDC,,,,,,inpatient,facility,25,UN,0.46,0.46,0.04,0.46,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,
VENLAFAXINE HCL 25 MG TAB,2500018081,CDM,637,RC,5140745390,NDC,,,,,,outpatient,facility,25,UN,0.46,0.46,0.04,618.77,,0.27,,,percent of total billed charges,,,0.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,0.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.41,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.17,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.46,,,fee schedule,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,0.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.32,,,percent of total billed charges,,
VENLAFAXINE HCL 25 MG TAB,2500018081,CDM,637,RC,5140745390,NDC,999,EAPG,,,,outpatient,facility,25,UN,0.46,0.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VENLAFAXINE HCL 37.5 MG TAB,2500018082,CDM,637,RC,6808484401,NDC,,,,,,inpatient,facility,37.5,UN,6.6,6.6,0.53,6.6,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,3.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,
VENLAFAXINE HCL 37.5 MG TAB,2500018082,CDM,637,RC,6808484401,NDC,,,,,,outpatient,facility,37.5,UN,6.6,6.6,0.53,618.77,,3.85,,,percent of total billed charges,,,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.6,,,percent of total billed charges,,,5.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.94,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,4.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,3.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.44,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,6.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.53,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,6.6,,,fee schedule,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,6.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.63,,,percent of total billed charges,,
VENLAFAXINE HCL 37.5 MG TAB,2500018082,CDM,637,RC,6808484401,NDC,999,EAPG,,,,outpatient,facility,37.5,UN,6.6,6.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VENLAFAXINE HCL SR 37.5 MG CAP,2500018086,CDM,637,RC,6586252790,NDC,,,,,,inpatient,facility,37.5,UN,13.72,13.72,1.1,13.72,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.35,,,percent of total billed charges,,,,,,,,,13.72,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,7.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.63,,,percent of total billed charges,,
VENLAFAXINE HCL SR 37.5 MG CAP,2500018086,CDM,637,RC,6586252790,NDC,,,,,,outpatient,facility,37.5,UN,13.72,13.72,1.1,618.77,,8.01,,,percent of total billed charges,,,2.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.72,,,percent of total billed charges,,,12.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.35,,,percent of total billed charges,,,,,,,,,13.72,,,percent of total billed charges,,,9.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.54,,,percent of total billed charges,,,,,,,,,,,,,,,7.41,,,percent of total billed charges,,,7.41,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.15,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.43,,,percent of total billed charges,,,5.2,,,percent of total billed charges,,,7.11,,,percent of total billed charges,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.08,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,13.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,13.72,,,fee schedule,,,12.76,,,percent of total billed charges,,,,,,,,,,,,,,,12.76,,,percent of total billed charges,,,12.76,,,percent of total billed charges,,,12.76,,,percent of total billed charges,,,10.29,,,percent of total billed charges,,,13.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.63,,,percent of total billed charges,,
VENLAFAXINE HCL SR 37.5 MG CAP,2500018086,CDM,637,RC,6586252790,NDC,999,EAPG,,,,outpatient,facility,37.5,UN,13.72,13.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VENLAFAXINE HCL SR 75 MG CAP,2500018087,CDM,637,RC,6586252890,NDC,,,,,,inpatient,facility,75,UN,15.41,15.41,1.23,15.41,,,,,,,,,,,,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.87,,,percent of total billed charges,,,,,,,,,15.41,,,percent of total billed charges,,,8.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,15.41,,,percent of total billed charges,,,8.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,
VENLAFAXINE HCL SR 75 MG CAP,2500018087,CDM,637,RC,6586252890,NDC,,,,,,outpatient,facility,75,UN,15.41,15.41,1.23,618.77,,9,,,percent of total billed charges,,,3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,15.41,,,percent of total billed charges,,,13.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,13.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,13.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.87,,,percent of total billed charges,,,,,,,,,15.41,,,percent of total billed charges,,,10.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.83,,,percent of total billed charges,,,,,,,,,,,,,,,8.32,,,percent of total billed charges,,,8.32,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.03,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.71,,,percent of total billed charges,,,5.84,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,3.08,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.7,,,percent of total billed charges,,,5.7,,,percent of total billed charges,,,15.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.23,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,15.41,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,,,,,,,15.41,,,fee schedule,,,14.33,,,percent of total billed charges,,,,,,,,,,,,,,,14.33,,,percent of total billed charges,,,14.33,,,percent of total billed charges,,,14.33,,,percent of total billed charges,,,11.56,,,percent of total billed charges,,,15.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,15.41,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.82,,,percent of total billed charges,,
VENLAFAXINE HCL SR 75 MG CAP,2500018087,CDM,637,RC,6586252890,NDC,999,EAPG,,,,outpatient,facility,75,UN,15.41,15.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VERAPAMIL 2.5 MG/ML 2 ML INJ,2500018101,CDM,250,RC,7012115855,NDC,,,,,,inpatient,facility,2,UN,120.22,120.22,9.62,120.22,,,,,,,,,,,,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.2,,,percent of total billed charges,,,,,,,,,120.22,,,percent of total billed charges,,,66.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,120.22,,,percent of total billed charges,,,62.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.62,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.42,,,percent of total billed charges,,
VERAPAMIL 2.5 MG/ML 2 ML INJ,2500018101,CDM,250,RC,7012115855,NDC,,,,,,outpatient,facility,2,UN,120.22,120.22,9.62,618.77,,70.21,,,percent of total billed charges,,,23.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,120.22,,,percent of total billed charges,,,105.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,105.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,105.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,108.2,,,percent of total billed charges,,,,,,,,,120.22,,,percent of total billed charges,,,81.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.68,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.37,,,percent of total billed charges,,,45.54,,,percent of total billed charges,,,62.26,,,percent of total billed charges,,,,,,,,,,,,,,,24.04,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,48.09,,,percent of total billed charges,,,48.09,,,percent of total billed charges,,,120.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,120.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.62,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,120.22,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,,,,,,,120.22,,,fee schedule,,,48.09,,,percent of total billed charges,,,,,,,,,,,,,,,48.09,,,percent of total billed charges,,,48.09,,,percent of total billed charges,,,48.09,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,120.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,120.22,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.11,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,84.42,,,percent of total billed charges,,
VERAPAMIL 2.5 MG/ML 2 ML INJ,2500018101,CDM,250,RC,7012115855,NDC,999,EAPG,,,,outpatient,facility,2,UN,120.22,120.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VERAPAMIL HCL 80 MG TAB,2500018104,CDM,637,RC,2315502601,NDC,,,,,,inpatient,facility,80,UN,1.02,1.02,0.08,1.02,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,
VERAPAMIL HCL 80 MG TAB,2500018104,CDM,637,RC,2315502601,NDC,,,,,,outpatient,facility,80,UN,1.02,1.02,0.08,618.77,,0.6,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.02,,,percent of total billed charges,,,0.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.92,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.38,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,1.02,,,fee schedule,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,1.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.72,,,percent of total billed charges,,
VERAPAMIL HCL 80 MG TAB,2500018104,CDM,637,RC,2315502601,NDC,999,EAPG,,,,outpatient,facility,80,UN,1.02,1.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VERAPAMIL HCL 120 MG TAB,2500018105,CDM,637,RC,1054457030,NDC,,,,,,inpatient,facility,120,UN,2.01,2.01,0.16,2.01,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,
VERAPAMIL HCL 120 MG TAB,2500018105,CDM,637,RC,1054457030,NDC,,,,,,outpatient,facility,120,UN,2.01,2.01,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.01,,,percent of total billed charges,,,1.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.81,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,2.01,,,fee schedule,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,2.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.41,,,percent of total billed charges,,
VERAPAMIL HCL 120 MG TAB,2500018105,CDM,637,RC,1054457030,NDC,999,EAPG,,,,outpatient,facility,120,UN,2.01,2.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VERAPAMIL HCL 180 MG SR TAB,2500018113,CDM,637,RC,6846229301,NDC,,,,,,inpatient,facility,180,UN,4.75,4.75,0.38,4.75,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,,,,,,,4.75,,,percent of total billed charges,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.34,,,percent of total billed charges,,
VERAPAMIL HCL 180 MG SR TAB,2500018113,CDM,637,RC,6846229301,NDC,,,,,,outpatient,facility,180,UN,4.75,4.75,0.38,618.77,,2.77,,,percent of total billed charges,,,0.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.75,,,percent of total billed charges,,,4.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.28,,,percent of total billed charges,,,,,,,,,4.75,,,percent of total billed charges,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.65,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.61,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.76,,,percent of total billed charges,,,1.76,,,percent of total billed charges,,,4.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.38,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,4.75,,,fee schedule,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,4.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.34,,,percent of total billed charges,,
VERAPAMIL HCL 180 MG SR TAB,2500018113,CDM,637,RC,6846229301,NDC,999,EAPG,,,,outpatient,facility,180,UN,4.75,4.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VERAPAMIL HCL 240 MG SR TAB,2500018114,CDM,637,RC,6846226001,NDC,,,,,,inpatient,facility,240,UN,5.41,5.41,0.43,5.41,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.87,,,percent of total billed charges,,,,,,,,,5.41,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,2.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,
VERAPAMIL HCL 240 MG SR TAB,2500018114,CDM,637,RC,6846226001,NDC,,,,,,outpatient,facility,240,UN,5.41,5.41,0.43,618.77,,3.16,,,percent of total billed charges,,,1.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.41,,,percent of total billed charges,,,4.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.87,,,percent of total billed charges,,,,,,,,,5.41,,,percent of total billed charges,,,3.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.15,,,percent of total billed charges,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.82,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.11,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,5.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.43,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,5.41,,,fee schedule,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,5.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.8,,,percent of total billed charges,,
VERAPAMIL HCL 240 MG SR TAB,2500018114,CDM,637,RC,6846226001,NDC,999,EAPG,,,,outpatient,facility,240,UN,5.41,5.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VITAMIN B COMPLEX/VIT C TAB,2500018195,CDM,637,RC,536730001,NDC,,,,,,inpatient,facility,0.8,UN,0.54,0.54,0.04,0.54,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,0.54,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,
VITAMIN B COMPLEX/VIT C TAB,2500018195,CDM,637,RC,536730001,NDC,,,,,,outpatient,facility,0.8,UN,0.54,0.54,0.04,618.77,,0.32,,,percent of total billed charges,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.54,,,percent of total billed charges,,,0.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.49,,,percent of total billed charges,,,,,,,,,0.54,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,0.54,,,fee schedule,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,0.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.54,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.38,,,percent of total billed charges,,
VITAMIN B COMPLEX/VIT C TAB,2500018195,CDM,637,RC,536730001,NDC,999,EAPG,,,,outpatient,facility,0.8,UN,0.54,0.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VITAMIN E 400 IU CAPSULE,2500018212,CDM,637,RC,7733395110,NDC,,,,,,inpatient,facility,400,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
VITAMIN E 400 IU CAPSULE,2500018212,CDM,637,RC,7733395110,NDC,,,,,,outpatient,facility,400,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
VITAMIN E 400 IU CAPSULE,2500018212,CDM,637,RC,7733395110,NDC,999,EAPG,,,,outpatient,facility,400,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WARFARIN SOD 1 MG TAB,2500018230,CDM,637,RC,832121101,NDC,,,,,,inpatient,facility,1,UN,2.01,2.01,0.16,2.01,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,
WARFARIN SOD 1 MG TAB,2500018230,CDM,637,RC,832121101,NDC,,,,,,outpatient,facility,1,UN,2.01,2.01,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.01,,,percent of total billed charges,,,1.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.81,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,2.01,,,fee schedule,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,2.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.41,,,percent of total billed charges,,
WARFARIN SOD 1 MG TAB,2500018230,CDM,637,RC,832121101,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.01,2.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WARFARIN SOD 2 MG TAB,2500018232,CDM,637,RC,832121201,NDC,,,,,,inpatient,facility,2,UN,2.11,2.11,0.17,2.11,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,2.11,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,
WARFARIN SOD 2 MG TAB,2500018232,CDM,637,RC,832121201,NDC,,,,,,outpatient,facility,2,UN,2.11,2.11,0.17,618.77,,1.23,,,percent of total billed charges,,,0.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.11,,,percent of total billed charges,,,1.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.9,,,percent of total billed charges,,,,,,,,,2.11,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.78,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,2.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,2.11,,,fee schedule,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,2.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.48,,,percent of total billed charges,,
WARFARIN SOD 2 MG TAB,2500018232,CDM,637,RC,832121201,NDC,999,EAPG,,,,outpatient,facility,2,UN,2.11,2.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WARFARIN SOD 2.5 MG TAB,2500018233,CDM,637,RC,832121301,NDC,,,,,,inpatient,facility,2.5,UN,2.18,2.18,0.17,2.18,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,
WARFARIN SOD 2.5 MG TAB,2500018233,CDM,637,RC,832121301,NDC,,,,,,outpatient,facility,2.5,UN,2.18,2.18,0.17,618.77,,1.27,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.18,,,percent of total billed charges,,,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.96,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.81,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,2.18,,,fee schedule,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,2.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.53,,,percent of total billed charges,,
WARFARIN SOD 2.5 MG TAB,2500018233,CDM,637,RC,832121301,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,2.18,2.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WARFARIN SOD 3 MG TAB,2500018234,CDM,637,RC,93171501,NDC,,,,,,inpatient,facility,3,UN,2.18,2.18,0.17,2.18,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,
WARFARIN SOD 3 MG TAB,2500018234,CDM,637,RC,93171501,NDC,,,,,,outpatient,facility,3,UN,2.18,2.18,0.17,618.77,,1.27,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.18,,,percent of total billed charges,,,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.96,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.81,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,2.18,,,fee schedule,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,2.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.53,,,percent of total billed charges,,
WARFARIN SOD 3 MG TAB,2500018234,CDM,637,RC,93171501,NDC,999,EAPG,,,,outpatient,facility,3,UN,2.18,2.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WARFARIN SOD 5 MG TAB,2500018235,CDM,637,RC,832121601,NDC,,,,,,inpatient,facility,5,UN,2.28,2.28,0.18,2.28,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,2.28,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,
WARFARIN SOD 5 MG TAB,2500018235,CDM,637,RC,832121601,NDC,,,,,,outpatient,facility,5,UN,2.28,2.28,0.18,618.77,,1.33,,,percent of total billed charges,,,0.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.28,,,percent of total billed charges,,,2.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.05,,,percent of total billed charges,,,,,,,,,2.28,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.84,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,2.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,2.28,,,fee schedule,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,2.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.6,,,percent of total billed charges,,
WARFARIN SOD 5 MG TAB,2500018235,CDM,637,RC,832121601,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.28,2.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WARFARIN SOD 7.5 MG TAB,2500018236,CDM,637,RC,832121801,NDC,,,,,,inpatient,facility,7.5,UN,3.04,3.04,0.24,3.04,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,3.04,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,
WARFARIN SOD 7.5 MG TAB,2500018236,CDM,637,RC,832121801,NDC,,,,,,outpatient,facility,7.5,UN,3.04,3.04,0.24,618.77,,1.78,,,percent of total billed charges,,,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.04,,,percent of total billed charges,,,2.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.74,,,percent of total billed charges,,,,,,,,,3.04,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,3.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,3.04,,,fee schedule,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,2.83,,,percent of total billed charges,,,2.83,,,percent of total billed charges,,,2.83,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,3.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.04,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.13,,,percent of total billed charges,,
WARFARIN SOD 7.5 MG TAB,2500018236,CDM,637,RC,832121801,NDC,999,EAPG,,,,outpatient,facility,7.5,UN,3.04,3.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WATER BACTERIOSTATIC 30ML INJ,2500018240,CDM,250,RC,409397703,NDC,,,,,,inpatient,facility,30,UN,5.97,5.97,0.48,5.97,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.37,,,percent of total billed charges,,,,,,,,,5.97,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,3.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,
WATER BACTERIOSTATIC 30ML INJ,2500018240,CDM,250,RC,409397703,NDC,,,,,,outpatient,facility,30,UN,5.97,5.97,0.48,618.77,,3.49,,,percent of total billed charges,,,1.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.97,,,percent of total billed charges,,,5.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.37,,,percent of total billed charges,,,,,,,,,5.97,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.11,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.54,,,percent of total billed charges,,,2.26,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,5.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.48,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,5.97,,,fee schedule,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,4.48,,,percent of total billed charges,,,5.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.97,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.19,,,percent of total billed charges,,
WATER BACTERIOSTATIC 30ML INJ,2500018240,CDM,250,RC,409397703,NDC,999,EAPG,,,,outpatient,facility,30,UN,5.97,5.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WATER FOR IRRIGATION 1000 ML,2500018250,CDM,250,RC,264210100,NDC,,,,,,inpatient,facility,1000,UN,33,33,2.64,33,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,17.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.17,,,percent of total billed charges,,
WATER FOR IRRIGATION 1000 ML,2500018250,CDM,250,RC,264210100,NDC,,,,,,outpatient,facility,1000,UN,33,33,2.64,618.77,,19.27,,,percent of total billed charges,,,6.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,33,,,percent of total billed charges,,,29.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,29.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,29.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,12.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,29.7,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,22.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.21,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.08,,,percent of total billed charges,,,12.5,,,percent of total billed charges,,,17.09,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,33,,,fee schedule,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,23.17,,,percent of total billed charges,,
WATER FOR IRRIGATION 1000 ML,2500018250,CDM,250,RC,264210100,NDC,999,EAPG,,,,outpatient,facility,1000,UN,33,33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WATER STERILE INJ 10 ML VIAL,2500018261,CDM,250,RC,6332318510,NDC,,,,,,inpatient,facility,10,UN,14.49,14.49,1.16,14.49,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,,,,,,,14.49,,,percent of total billed charges,,,8.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.17,,,percent of total billed charges,,
WATER STERILE INJ 10 ML VIAL,2500018261,CDM,250,RC,6332318510,NDC,,,,,,outpatient,facility,10,UN,14.49,14.49,1.16,618.77,,8.46,,,percent of total billed charges,,,2.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.49,,,percent of total billed charges,,,12.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.04,,,percent of total billed charges,,,,,,,,,14.49,,,percent of total billed charges,,,9.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.01,,,percent of total billed charges,,,5.49,,,percent of total billed charges,,,7.5,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.8,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,14.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.16,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,14.49,,,fee schedule,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,10.87,,,percent of total billed charges,,,14.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.17,,,percent of total billed charges,,
WATER STERILE INJ 10 ML VIAL,2500018261,CDM,250,RC,6332318510,NDC,999,EAPG,,,,outpatient,facility,10,UN,14.49,14.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WATER STERILE INJ 1000 ML,2500018267,CDM,250,RC,264785000,NDC,,,,,,inpatient,facility,1000,UN,14.26,14.26,1.14,14.26,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.83,,,percent of total billed charges,,,,,,,,,14.26,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,7.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.01,,,percent of total billed charges,,
WATER STERILE INJ 1000 ML,2500018267,CDM,250,RC,264785000,NDC,,,,,,outpatient,facility,1000,UN,14.26,14.26,1.14,618.77,,8.33,,,percent of total billed charges,,,2.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.26,,,percent of total billed charges,,,12.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.83,,,percent of total billed charges,,,,,,,,,14.26,,,percent of total billed charges,,,9.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.44,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.84,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.7,,,percent of total billed charges,,,5.7,,,percent of total billed charges,,,14.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.14,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,14.26,,,fee schedule,,,5.7,,,percent of total billed charges,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,5.7,,,percent of total billed charges,,,5.7,,,percent of total billed charges,,,10.7,,,percent of total billed charges,,,14.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.26,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.01,,,percent of total billed charges,,
WATER STERILE INJ 1000 ML,2500018267,CDM,250,RC,264785000,NDC,999,EAPG,,,,outpatient,facility,1000,UN,14.26,14.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WITCH HAZEL/GLYCERIN 40PAD JAR,2500018290,CDM,637,RC,4138800730,NDC,,,,,,inpatient,facility,40,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
WITCH HAZEL/GLYCERIN 40PAD JAR,2500018290,CDM,637,RC,4138800730,NDC,,,,,,outpatient,facility,40,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
WITCH HAZEL/GLYCERIN 40PAD JAR,2500018290,CDM,637,RC,4138800730,NDC,999,EAPG,,,,outpatient,facility,40,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZINC OXIDE 40  OINT 120 GM,2500018364,CDM,637,RC,7430000071,NDC,,,,,,inpatient,facility,114,UN,8.82,8.82,0.71,8.82,,,,,,,,,,,,,,8.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.94,,,percent of total billed charges,,,,,,,,,8.82,,,percent of total billed charges,,,4.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.82,,,percent of total billed charges,,,,,,,,,,,,,,,8.82,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,8.82,,,percent of total billed charges,,,8.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,
ZINC OXIDE 40  OINT 120 GM,2500018364,CDM,637,RC,7430000071,NDC,,,,,,outpatient,facility,114,UN,8.82,8.82,0.71,618.77,,5.15,,,percent of total billed charges,,,1.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.82,,,percent of total billed charges,,,7.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.94,,,percent of total billed charges,,,,,,,,,8.82,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.77,,,percent of total billed charges,,,,,,,,,,,,,,,4.76,,,percent of total billed charges,,,4.76,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.6,,,percent of total billed charges,,,8.82,,,percent of total billed charges,,,8.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,3.34,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,8.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.71,,,percent of total billed charges,,,8.82,,,percent of total billed charges,,,8.82,,,percent of total billed charges,,,,,,,,,,,,,,,8.82,,,percent of total billed charges,,,8.82,,,percent of total billed charges,,,,,,,,,8.82,,,fee schedule,,,8.2,,,percent of total billed charges,,,,,,,,,,,,,,,8.2,,,percent of total billed charges,,,8.2,,,percent of total billed charges,,,8.2,,,percent of total billed charges,,,6.62,,,percent of total billed charges,,,8.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.82,,,percent of total billed charges,,,8.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.19,,,percent of total billed charges,,
ZINC OXIDE 40  OINT 120 GM,2500018364,CDM,637,RC,7430000071,NDC,999,EAPG,,,,outpatient,facility,114,UN,8.82,8.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZINC SULF 220 MG CAP,2500018382,CDM,637,RC,7733398310,NDC,,,,,,inpatient,facility,220,UN,1.3,1.3,0.1,1.3,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,,,,,,,1.3,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,
ZINC SULF 220 MG CAP,2500018382,CDM,637,RC,7733398310,NDC,,,,,,outpatient,facility,220,UN,1.3,1.3,0.1,618.77,,0.76,,,percent of total billed charges,,,0.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.3,,,percent of total billed charges,,,1.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.17,,,percent of total billed charges,,,,,,,,,1.3,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.48,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,1.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,1.3,,,fee schedule,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,1.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.3,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.91,,,percent of total billed charges,,
ZINC SULF 220 MG CAP,2500018382,CDM,637,RC,7733398310,NDC,999,EAPG,,,,outpatient,facility,220,UN,1.3,1.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZIPRASIDONE 20 MG CAP,2500018390,CDM,637,RC,5511125660,NDC,,,,,,inpatient,facility,20,UN,29.24,29.24,2.34,29.24,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.32,,,percent of total billed charges,,,,,,,,,29.24,,,percent of total billed charges,,,16.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,15.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.53,,,percent of total billed charges,,
ZIPRASIDONE 20 MG CAP,2500018390,CDM,637,RC,5511125660,NDC,,,,,,outpatient,facility,20,UN,29.24,29.24,2.34,618.77,,17.08,,,percent of total billed charges,,,5.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,29.24,,,percent of total billed charges,,,25.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,25.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,25.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26.32,,,percent of total billed charges,,,,,,,,,29.24,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.46,,,percent of total billed charges,,,,,,,,,,,,,,,15.79,,,percent of total billed charges,,,15.79,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.25,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.22,,,percent of total billed charges,,,11.08,,,percent of total billed charges,,,15.14,,,percent of total billed charges,,,,,,,,,,,,,,,5.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.82,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,29.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.34,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,,,,,,,29.24,,,fee schedule,,,27.2,,,percent of total billed charges,,,,,,,,,,,,,,,27.2,,,percent of total billed charges,,,27.2,,,percent of total billed charges,,,27.2,,,percent of total billed charges,,,21.93,,,percent of total billed charges,,,29.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,29.24,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.62,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.53,,,percent of total billed charges,,
ZIPRASIDONE 20 MG CAP,2500018390,CDM,637,RC,5511125660,NDC,999,EAPG,,,,outpatient,facility,20,UN,29.24,29.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZIPRASIDONE 40 MG CAP,2500018391,CDM,637,RC,5511125760,NDC,,,,,,inpatient,facility,40,UN,29.24,29.24,2.34,29.24,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.32,,,percent of total billed charges,,,,,,,,,29.24,,,percent of total billed charges,,,16.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,15.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.53,,,percent of total billed charges,,
ZIPRASIDONE 40 MG CAP,2500018391,CDM,637,RC,5511125760,NDC,,,,,,outpatient,facility,40,UN,29.24,29.24,2.34,618.77,,17.08,,,percent of total billed charges,,,5.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,29.24,,,percent of total billed charges,,,25.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,25.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,25.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26.32,,,percent of total billed charges,,,,,,,,,29.24,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.46,,,percent of total billed charges,,,,,,,,,,,,,,,15.79,,,percent of total billed charges,,,15.79,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.25,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.22,,,percent of total billed charges,,,11.08,,,percent of total billed charges,,,15.14,,,percent of total billed charges,,,,,,,,,,,,,,,5.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.82,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,29.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.34,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,,,,,,,29.24,,,fee schedule,,,27.2,,,percent of total billed charges,,,,,,,,,,,,,,,27.2,,,percent of total billed charges,,,27.2,,,percent of total billed charges,,,27.2,,,percent of total billed charges,,,21.93,,,percent of total billed charges,,,29.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,29.24,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.62,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.53,,,percent of total billed charges,,
ZIPRASIDONE 40 MG CAP,2500018391,CDM,637,RC,5511125760,NDC,999,EAPG,,,,outpatient,facility,40,UN,29.24,29.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZIPRASIDONE 20 MG/ML INJ,2500018395,CDM,636,RC,J3486,HCPCS,7226616010,NDC,,,,inpatient,facility,20,UN,108.21,108.21,8.66,108.21,,,,,,,,,,,,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.39,,,percent of total billed charges,,,,,,,,,108.21,,,percent of total billed charges,,,59.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,108.21,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.66,,,percent of total billed charges,,,108.21,,,percent of total billed charges,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.99,,,percent of total billed charges,,
ZIPRASIDONE 20 MG/ML INJ,2500018395,CDM,636,RC,J3486,HCPCS,7226616010,NDC,,,,outpatient,facility,20,UN,108.21,108.21,8.38,618.77,,63.19,,,percent of total billed charges,,,21.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,108.21,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,39.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,97.39,,,percent of total billed charges,,,,,,,,,108.21,,,percent of total billed charges,,,73.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.42,,,percent of total billed charges,,,108.21,,,percent of total billed charges,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.24,,,percent of total billed charges,,,40.99,,,percent of total billed charges,,,56.04,,,percent of total billed charges,,,,,,,,,,,,,,,21.64,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,108.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,108.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.66,,,percent of total billed charges,,,108.21,,,percent of total billed charges,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,108.21,,,percent of total billed charges,,,108.21,,,percent of total billed charges,,,,,,,,,108.21,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,8.38,,,fee schedule,,,108.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,108.21,,,percent of total billed charges,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,75.99,,,percent of total billed charges,,
ZIPRASIDONE 20 MG/ML INJ,2500018395,CDM,636,RC,J3486,HCPCS,7226616010,NDC,435,EAPG,,outpatient,facility,20,UN,108.21,108.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZOLPIDEM TART 5 MG TAB,2500018401,CDM,637,RC,904608261,NDC,,,,,,inpatient,facility,5,UN,0.29,0.29,0.02,0.29,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,
ZOLPIDEM TART 5 MG TAB,2500018401,CDM,637,RC,904608261,NDC,,,,,,outpatient,facility,5,UN,0.29,0.29,0.02,618.77,,0.17,,,percent of total billed charges,,,0.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.29,,,percent of total billed charges,,,0.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.26,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.11,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,fee schedule,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.2,,,percent of total billed charges,,
ZOLPIDEM TART 5 MG TAB,2500018401,CDM,637,RC,904608261,NDC,999,EAPG,,,,outpatient,facility,5,UN,0.29,0.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE 0.25  30 ML INJ,2500018410,CDM,250,RC,5515016830,NDC,,,,,,inpatient,facility,30,UN,10.56,10.56,0.84,10.56,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,10.56,,,percent of total billed charges,,,5.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.42,,,percent of total billed charges,,
BUPIVACAINE 0.25  30 ML INJ,2500018410,CDM,250,RC,5515016830,NDC,,,,,,outpatient,facility,30,UN,10.56,10.56,0.84,618.77,,6.17,,,percent of total billed charges,,,2.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.56,,,percent of total billed charges,,,9.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,9.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,9.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.5,,,percent of total billed charges,,,,,,,,,10.56,,,percent of total billed charges,,,7.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.03,,,percent of total billed charges,,,4,,,percent of total billed charges,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.22,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,10.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.84,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,10.56,,,fee schedule,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,10.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.42,,,percent of total billed charges,,
BUPIVACAINE 0.25  30 ML INJ,2500018410,CDM,250,RC,5515016830,NDC,999,EAPG,,,,outpatient,facility,30,UN,10.56,10.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE 0.5  30 ML INJ,2500018411,CDM,250,RC,J3490,HCPCS,409116202,NDC,,,,inpatient,facility,30,UN,7.39,7.39,0.59,7.39,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.65,,,percent of total billed charges,,,,,,,,,7.39,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.19,,,percent of total billed charges,,
BUPIVACAINE 0.5  30 ML INJ,2500018411,CDM,250,RC,J3490,HCPCS,409116202,NDC,,,,outpatient,facility,30,UN,7.39,7.39,0.59,618.77,,4.32,,,percent of total billed charges,,,1.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,7.39,,,percent of total billed charges,,,6.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.65,,,percent of total billed charges,,,,,,,,,7.39,,,percent of total billed charges,,,5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.68,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.62,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,7.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,7.39,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,5.54,,,percent of total billed charges,,,7.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.19,,,percent of total billed charges,,
BUPIVACAINE 0.5  30 ML INJ,2500018411,CDM,250,RC,J3490,HCPCS,409116202,NDC,435,EAPG,,outpatient,facility,30,UN,7.39,7.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE 0.5  10 ML INJ,2500018414,CDM,250,RC,J3490,HCPCS,5515016910,NDC,,,,inpatient,facility,10,UN,11.88,11.88,0.95,11.88,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.69,,,percent of total billed charges,,,,,,,,,11.88,,,percent of total billed charges,,,6.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,6.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.34,,,percent of total billed charges,,
BUPIVACAINE 0.5  10 ML INJ,2500018414,CDM,250,RC,J3490,HCPCS,5515016910,NDC,,,,outpatient,facility,10,UN,11.88,11.88,0.95,618.77,,6.94,,,percent of total billed charges,,,2.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.88,,,percent of total billed charges,,,10.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,10.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,10.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.69,,,percent of total billed charges,,,,,,,,,11.88,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.12,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.03,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,6.15,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,11.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.95,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,11.88,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,8.91,,,percent of total billed charges,,,11.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.34,,,percent of total billed charges,,
BUPIVACAINE 0.5  10 ML INJ,2500018414,CDM,250,RC,J3490,HCPCS,5515016910,NDC,435,EAPG,,outpatient,facility,10,UN,11.88,11.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE/EPI 0.25  30ML INJ,2500018420,CDM,250,RC,J3490,HCPCS,6332346837,NDC,,,,inpatient,facility,30,UN,35.01,35.01,2.8,35.01,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.51,,,percent of total billed charges,,,,,,,,,35.01,,,percent of total billed charges,,,19.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,18.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,,35.01,,,percent of total billed charges,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.58,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.25  30ML INJ,2500018420,CDM,250,RC,J3490,HCPCS,6332346837,NDC,,,,outpatient,facility,30,UN,35.01,35.01,1.2,618.77,,20.45,,,percent of total billed charges,,,6.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,35.01,,,percent of total billed charges,,,30.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,30.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,30.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,12.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,31.51,,,percent of total billed charges,,,,,,,,,35.01,,,percent of total billed charges,,,23.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.89,,,percent of total billed charges,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,35.01,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.25,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.61,,,percent of total billed charges,,,13.26,,,percent of total billed charges,,,18.13,,,percent of total billed charges,,,,,,,,,,,,,,,7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,35.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.8,,,percent of total billed charges,,,35.01,,,percent of total billed charges,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,35.01,,,percent of total billed charges,,,,,,,,,35.01,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,26.26,,,percent of total billed charges,,,35.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,35.01,,,percent of total billed charges,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,24.58,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.25  30ML INJ,2500018420,CDM,250,RC,J3490,HCPCS,6332346837,NDC,435,EAPG,,outpatient,facility,30,UN,35.01,35.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE/EPI 0.5  10 ML INJ,2500018422,CDM,250,RC,J3490,HCPCS,6332346217,NDC,,,,inpatient,facility,10,UN,22.7,22.7,1.82,22.7,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,,,,,,,22.7,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,11.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.94,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.5  10 ML INJ,2500018422,CDM,250,RC,J3490,HCPCS,6332346217,NDC,,,,outpatient,facility,10,UN,22.7,22.7,1.2,618.77,,13.26,,,percent of total billed charges,,,4.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,22.7,,,percent of total billed charges,,,19.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,19.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,19.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,20.43,,,percent of total billed charges,,,,,,,,,22.7,,,percent of total billed charges,,,15.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.43,,,percent of total billed charges,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.84,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.25,,,percent of total billed charges,,,8.6,,,percent of total billed charges,,,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,4.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,22.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.82,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,,,,,,,22.7,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,17.02,,,percent of total billed charges,,,22.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,22.7,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,15.94,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.5  10 ML INJ,2500018422,CDM,250,RC,J3490,HCPCS,6332346217,NDC,435,EAPG,,outpatient,facility,10,UN,22.7,22.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE/EPI 0.5  30 ML INJ,2500018423,CDM,250,RC,J3490,HCPCS,6332346237,NDC,,,,inpatient,facility,30,UN,37.72,37.72,3.02,37.72,,,,,,,,,,,,,,37.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.95,,,percent of total billed charges,,,,,,,,,37.72,,,percent of total billed charges,,,20.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.72,,,percent of total billed charges,,,,,,,,,,,,,,,37.72,,,percent of total billed charges,,,19.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.02,,,percent of total billed charges,,,37.72,,,percent of total billed charges,,,37.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.49,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.5  30 ML INJ,2500018423,CDM,250,RC,J3490,HCPCS,6332346237,NDC,,,,outpatient,facility,30,UN,37.72,37.72,1.2,618.77,,22.03,,,percent of total billed charges,,,7.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,37.72,,,percent of total billed charges,,,33.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,33.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,33.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,37.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,13.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,33.95,,,percent of total billed charges,,,,,,,,,37.72,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,37.72,,,percent of total billed charges,,,37.72,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,37.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.67,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.67,,,percent of total billed charges,,,14.29,,,percent of total billed charges,,,19.54,,,percent of total billed charges,,,,,,,,,,,,,,,7.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,37.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,37.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.02,,,percent of total billed charges,,,37.72,,,percent of total billed charges,,,37.72,,,percent of total billed charges,,,,,,,,,,,,,,,37.72,,,percent of total billed charges,,,37.72,,,percent of total billed charges,,,,,,,,,37.72,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,28.29,,,percent of total billed charges,,,37.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,37.72,,,percent of total billed charges,,,37.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.86,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,26.49,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.5  30 ML INJ,2500018423,CDM,250,RC,J3490,HCPCS,6332346237,NDC,435,EAPG,,outpatient,facility,30,UN,37.72,37.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETYLCYSTEINE INH 800 MG/4 ML,2500018470,CDM,637,RC,J7608,HCPCS,6332369404,NDC,,,,inpatient,facility,4,ML,52.7,52.7,4.22,52.7,,,,,,,,,,,,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,,,,,,,52.7,,,percent of total billed charges,,,29.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,52.7,,,percent of total billed charges,,,27.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.01,,,percent of total billed charges,,
ACETYLCYSTEINE INH 800 MG/4 ML,2500018470,CDM,637,RC,J7608,HCPCS,6332369404,NDC,,,,outpatient,facility,4,ML,52.7,52.7,4.22,618.77,,30.78,,,percent of total billed charges,,,10.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,52.7,,,percent of total billed charges,,,10.77,,,fee schedule,,,10.38,,,fee schedule,,,,,,,,,10.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,19.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,47.43,,,percent of total billed charges,,,,,,,,,52.7,,,percent of total billed charges,,,35.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.47,,,percent of total billed charges,,,,,,,,,,,,,,,6.83,,,fee schedule,,,6.83,,,fee schedule,,,,,,,,,618.77,,,per diem,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.48,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.05,,,percent of total billed charges,,,19.96,,,percent of total billed charges,,,27.29,,,percent of total billed charges,,,,,,,,,,,,,,,10.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,16.31,,,fee schedule,,,7.27,,,fee schedule,,,52.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,52.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.22,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,52.7,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,,,,,,,7.77,,,fee schedule,,,7.76,,,fee schedule,,,,,,,,,,,,,,,6.83,,,fee schedule,,,9.1,,,fee schedule,,,5.04,,,fee schedule,,,9.45,,,fee schedule,,,52.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,52.7,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,37.01,,,percent of total billed charges,,
ACETYLCYSTEINE INH 800 MG/4 ML,2500018470,CDM,637,RC,J7608,HCPCS,6332369404,NDC,496,EAPG,,outpatient,facility,4,ML,52.7,52.7,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETYLCYSTEINE 6 GM/30 ML IV,2500018475,CDM,636,RC,J0132,HCPCS,6332396330,NDC,,,,inpatient,facility,30,UN,363,363,29.04,363,,,,,,,,,,,,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,326.7,,,percent of total billed charges,,,,,,,,,363,,,percent of total billed charges,,,200.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,363,,,percent of total billed charges,,,189.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,363,,,percent of total billed charges,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.9,,,percent of total billed charges,,
ACETYLCYSTEINE 6 GM/30 ML IV,2500018475,CDM,636,RC,J0132,HCPCS,6332396330,NDC,,,,outpatient,facility,30,UN,363,363,0.59,618.77,,211.99,,,percent of total billed charges,,,70.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,363,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,132.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,326.7,,,percent of total billed charges,,,,,,,,,363,,,percent of total billed charges,,,245.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,fee schedule,,,0.7,,,fee schedule,,,,,,,,,618.77,,,per diem,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,189.27,,,percent of total billed charges,,,363,,,percent of total billed charges,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,275.88,,,percent of total billed charges,,,137.5,,,percent of total billed charges,,,188,,,percent of total billed charges,,,,,,,,,,,,,,,72.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,363,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,363,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.04,,,percent of total billed charges,,,363,,,percent of total billed charges,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,363,,,percent of total billed charges,,,363,,,percent of total billed charges,,,,,,,,,363,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,363,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,363,,,percent of total billed charges,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,254.9,,,percent of total billed charges,,
ACETYLCYSTEINE 6 GM/30 ML IV,2500018475,CDM,636,RC,J0132,HCPCS,6332396330,NDC,999,EAPG,,outpatient,facility,30,UN,363,363,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LETROZOLE 2.5 MG TAB,2500018500,CDM,637,RC,5199175933,NDC,,,,,,inpatient,facility,2.5,UN,59.76,59.76,4.78,59.76,,,,,,,,,,,,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.78,,,percent of total billed charges,,,,,,,,,59.76,,,percent of total billed charges,,,33.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,59.76,,,percent of total billed charges,,,31.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.96,,,percent of total billed charges,,
LETROZOLE 2.5 MG TAB,2500018500,CDM,637,RC,5199175933,NDC,,,,,,outpatient,facility,2.5,UN,59.76,59.76,4.78,618.77,,34.9,,,percent of total billed charges,,,11.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,59.76,,,percent of total billed charges,,,52.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,52.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,52.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,21.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,53.78,,,percent of total billed charges,,,,,,,,,59.76,,,percent of total billed charges,,,40.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,32.27,,,percent of total billed charges,,,32.27,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.16,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.42,,,percent of total billed charges,,,22.64,,,percent of total billed charges,,,30.95,,,percent of total billed charges,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,59.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,59.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.78,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,59.76,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,,,,,,,59.76,,,fee schedule,,,55.59,,,percent of total billed charges,,,,,,,,,,,,,,,55.59,,,percent of total billed charges,,,55.59,,,percent of total billed charges,,,55.59,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,59.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,59.76,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,41.96,,,percent of total billed charges,,
LETROZOLE 2.5 MG TAB,2500018500,CDM,637,RC,5199175933,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,59.76,59.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZOLEDRONIC ACID 4 MG/ZOMETA,2500018515,CDM,636,RC,J3489,HCPCS,1672924231,NDC,,,,inpatient,facility,5,UN,2766.36,2766.36,221.31,2766.36,,,,,,,,,,,,,,2766.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2489.72,,,percent of total billed charges,,,,,,,,,2766.36,,,percent of total billed charges,,,1531.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2524.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2766.36,,,percent of total billed charges,,,,,,,,,,,,,,,2766.36,,,percent of total billed charges,,,1442.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,553.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.31,,,percent of total billed charges,,,2766.36,,,percent of total billed charges,,,2766.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2766.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1942.54,,,percent of total billed charges,,
ZOLEDRONIC ACID 4 MG/ZOMETA,2500018515,CDM,636,RC,J3489,HCPCS,1672924231,NDC,,,,outpatient,facility,5,UN,2766.36,2766.36,5.94,2766.36,,1615.55,,,percent of total billed charges,,,539.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2766.36,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,2766.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1012.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2489.72,,,percent of total billed charges,,,,,,,,,2766.36,,,percent of total billed charges,,,1873.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2124.56,,,percent of total billed charges,,,,,,,,,,,,,,,7.21,,,fee schedule,,,7.21,,,fee schedule,,,,,,,,,618.77,,,per diem,,,2766.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1442.38,,,percent of total billed charges,,,2766.36,,,percent of total billed charges,,,2766.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2102.43,,,percent of total billed charges,,,1047.9,,,percent of total billed charges,,,1432.7,,,percent of total billed charges,,,,,,,,,,,,,,,553.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,2766.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2766.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,221.31,,,percent of total billed charges,,,2766.36,,,percent of total billed charges,,,2766.36,,,percent of total billed charges,,,,,,,,,,,,,,,2766.36,,,percent of total billed charges,,,2766.36,,,percent of total billed charges,,,,,,,,,2766.36,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,5.94,,,fee schedule,,,2766.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2766.36,,,percent of total billed charges,,,2766.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1383.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1942.54,,,percent of total billed charges,,
ZOLEDRONIC ACID 4 MG/ZOMETA,2500018515,CDM,636,RC,J3489,HCPCS,1672924231,NDC,435,EAPG,,outpatient,facility,5,UN,2766.36,2766.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZONISAMIDE 100 MG CAP,2500018520,CDM,637,RC,5026881615,NDC,,,,,,inpatient,facility,100,UN,5.67,5.67,0.45,5.67,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,,,,,,,5.67,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,2.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.98,,,percent of total billed charges,,
ZONISAMIDE 100 MG CAP,2500018520,CDM,637,RC,5026881615,NDC,,,,,,outpatient,facility,100,UN,5.67,5.67,0.45,618.77,,3.31,,,percent of total billed charges,,,1.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.67,,,percent of total billed charges,,,4.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.1,,,percent of total billed charges,,,,,,,,,5.67,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,3.06,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.31,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.1,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,5.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.45,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,,,,,,,5.67,,,fee schedule,,,5.27,,,percent of total billed charges,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,5.27,,,percent of total billed charges,,,5.27,,,percent of total billed charges,,,4.25,,,percent of total billed charges,,,5.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.67,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.98,,,percent of total billed charges,,
ZONISAMIDE 100 MG CAP,2500018520,CDM,637,RC,5026881615,NDC,999,EAPG,,,,outpatient,facility,100,UN,5.67,5.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZONISAMIDE 25 MG,2500018523,CDM,637,RC,6846212801,NDC,,,,,,inpatient,facility,25,UN,1.81,1.81,0.14,1.81,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,,,,,,,1.81,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,
ZONISAMIDE 25 MG,2500018523,CDM,637,RC,6846212801,NDC,,,,,,outpatient,facility,25,UN,1.81,1.81,0.14,618.77,,1.06,,,percent of total billed charges,,,0.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.81,,,percent of total billed charges,,,1.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.63,,,percent of total billed charges,,,,,,,,,1.81,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.67,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,1.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.14,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,1.81,,,fee schedule,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,1.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.27,,,percent of total billed charges,,
ZONISAMIDE 25 MG,2500018523,CDM,637,RC,6846212801,NDC,999,EAPG,,,,outpatient,facility,25,UN,1.81,1.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MODAFINIL 100 MG TAB,2500018530,CDM,637,RC,6233238530,NDC,,,,,,inpatient,facility,100,UN,72.83,72.83,5.83,72.83,,,,,,,,,,,,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.55,,,percent of total billed charges,,,,,,,,,72.83,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,72.83,,,percent of total billed charges,,,37.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.83,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.14,,,percent of total billed charges,,
MODAFINIL 100 MG TAB,2500018530,CDM,637,RC,6233238530,NDC,,,,,,outpatient,facility,100,UN,72.83,72.83,5.83,618.77,,42.53,,,percent of total billed charges,,,14.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,72.83,,,percent of total billed charges,,,64.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,64.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,64.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,26.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,65.55,,,percent of total billed charges,,,,,,,,,72.83,,,percent of total billed charges,,,49.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.93,,,percent of total billed charges,,,,,,,,,,,,,,,39.33,,,percent of total billed charges,,,39.33,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.97,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.35,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,37.72,,,percent of total billed charges,,,,,,,,,,,,,,,14.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,26.95,,,percent of total billed charges,,,26.95,,,percent of total billed charges,,,72.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,72.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.83,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,72.83,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,,,,,,,72.83,,,fee schedule,,,67.75,,,percent of total billed charges,,,,,,,,,,,,,,,67.75,,,percent of total billed charges,,,67.75,,,percent of total billed charges,,,67.75,,,percent of total billed charges,,,54.62,,,percent of total billed charges,,,72.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,72.83,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,51.14,,,percent of total billed charges,,
MODAFINIL 100 MG TAB,2500018530,CDM,637,RC,6233238530,NDC,999,EAPG,,,,outpatient,facility,100,UN,72.83,72.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRANEXAMIC ACID 650 MG TAB,2500018575,CDM,637,RC,6991830130,NDC,,,,,,inpatient,facility,650,UN,17.19,17.19,1.38,17.19,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.47,,,percent of total billed charges,,,,,,,,,17.19,,,percent of total billed charges,,,9.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,8.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,
TRANEXAMIC ACID 650 MG TAB,2500018575,CDM,637,RC,6991830130,NDC,,,,,,outpatient,facility,650,UN,17.19,17.19,1.38,618.77,,10.04,,,percent of total billed charges,,,3.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,17.19,,,percent of total billed charges,,,15.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,15.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,15.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,15.47,,,percent of total billed charges,,,,,,,,,17.19,,,percent of total billed charges,,,11.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,9.28,,,percent of total billed charges,,,9.28,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.96,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.06,,,percent of total billed charges,,,6.51,,,percent of total billed charges,,,8.9,,,percent of total billed charges,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.36,,,percent of total billed charges,,,6.36,,,percent of total billed charges,,,17.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.38,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,,,,,,,17.19,,,fee schedule,,,15.99,,,percent of total billed charges,,,,,,,,,,,,,,,15.99,,,percent of total billed charges,,,15.99,,,percent of total billed charges,,,15.99,,,percent of total billed charges,,,12.89,,,percent of total billed charges,,,17.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,17.19,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,12.07,,,percent of total billed charges,,
TRANEXAMIC ACID 650 MG TAB,2500018575,CDM,637,RC,6991830130,NDC,999,EAPG,,,,outpatient,facility,650,UN,17.19,17.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 2 /EPI 1 200000 20ML,2500018640,CDM,250,RC,J2004,HCPCS,6332348927,NDC,,,,inpatient,facility,20,UN,68.01,68.01,5.44,68.01,,,,,,,,,,,,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.21,,,percent of total billed charges,,,,,,,,,68.01,,,percent of total billed charges,,,37.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,68.01,,,percent of total billed charges,,,35.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.76,,,percent of total billed charges,,
LIDOCAINE 2 /EPI 1 200000 20ML,2500018640,CDM,250,RC,J2004,HCPCS,6332348927,NDC,,,,outpatient,facility,20,UN,68.01,68.01,5.44,618.77,,39.72,,,percent of total billed charges,,,13.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,68.01,,,percent of total billed charges,,,59.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,59.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,59.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,24.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,61.21,,,percent of total billed charges,,,,,,,,,68.01,,,percent of total billed charges,,,46.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.46,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.69,,,percent of total billed charges,,,25.76,,,percent of total billed charges,,,35.22,,,percent of total billed charges,,,,,,,,,,,,,,,13.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,25.16,,,percent of total billed charges,,,25.16,,,percent of total billed charges,,,68.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,68.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.44,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,68.01,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,,,,,,,68.01,,,fee schedule,,,63.26,,,percent of total billed charges,,,,,,,,,,,,,,,63.26,,,percent of total billed charges,,,63.26,,,percent of total billed charges,,,63.26,,,percent of total billed charges,,,51.01,,,percent of total billed charges,,,68.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,68.01,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,47.76,,,percent of total billed charges,,
LIDOCAINE 2 /EPI 1 200000 20ML,2500018640,CDM,250,RC,J2004,HCPCS,6332348927,NDC,999,EAPG,,outpatient,facility,20,UN,68.01,68.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 2 /EPI 1 100000 20ML,2500018641,CDM,250,RC,J2004,HCPCS,6332348327,NDC,,,,inpatient,facility,20,UN,16.43,16.43,1.31,16.43,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.79,,,percent of total billed charges,,,,,,,,,16.43,,,percent of total billed charges,,,9.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,8.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.54,,,percent of total billed charges,,
LIDOCAINE 2 /EPI 1 100000 20ML,2500018641,CDM,250,RC,J2004,HCPCS,6332348327,NDC,,,,outpatient,facility,20,UN,16.43,16.43,1.31,618.77,,9.6,,,percent of total billed charges,,,3.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.43,,,percent of total billed charges,,,14.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,14.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,14.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,14.79,,,percent of total billed charges,,,,,,,,,16.43,,,percent of total billed charges,,,11.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.57,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,6.22,,,percent of total billed charges,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,3.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.08,,,percent of total billed charges,,,6.08,,,percent of total billed charges,,,16.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.31,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,,,,,,,16.43,,,fee schedule,,,15.28,,,percent of total billed charges,,,,,,,,,,,,,,,15.28,,,percent of total billed charges,,,15.28,,,percent of total billed charges,,,15.28,,,percent of total billed charges,,,12.32,,,percent of total billed charges,,,16.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.43,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.54,,,percent of total billed charges,,
LIDOCAINE 2 /EPI 1 100000 20ML,2500018641,CDM,250,RC,J2004,HCPCS,6332348327,NDC,999,EAPG,,outpatient,facility,20,UN,16.43,16.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 1 /EPI 1 100000 20ML,2500018644,CDM,250,RC,J2004,HCPCS,6332348227,NDC,,,,inpatient,facility,20,UN,16.2,16.2,1.3,16.2,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.58,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,8.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.38,,,percent of total billed charges,,
LIDOCAINE 1 /EPI 1 100000 20ML,2500018644,CDM,250,RC,J2004,HCPCS,6332348227,NDC,,,,outpatient,facility,20,UN,16.2,16.2,1.3,618.77,,9.46,,,percent of total billed charges,,,3.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.2,,,percent of total billed charges,,,14.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,14.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,14.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,14.58,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,10.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.31,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,8.39,,,percent of total billed charges,,,,,,,,,,,,,,,3.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.99,,,percent of total billed charges,,,5.99,,,percent of total billed charges,,,16.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.3,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,16.2,,,fee schedule,,,15.07,,,percent of total billed charges,,,,,,,,,,,,,,,15.07,,,percent of total billed charges,,,15.07,,,percent of total billed charges,,,15.07,,,percent of total billed charges,,,12.15,,,percent of total billed charges,,,16.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.2,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.38,,,percent of total billed charges,,
LIDOCAINE 1 /EPI 1 100000 20ML,2500018644,CDM,250,RC,J2004,HCPCS,6332348227,NDC,999,EAPG,,outpatient,facility,20,UN,16.2,16.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF PF 5 MG/10 ML,2500018652,CDM,636,RC,J2274,HCPCS,641602010,NDC,,,,inpatient,facility,10,UN,95.57,95.57,7.65,95.57,,,,,,,,,,,,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.01,,,percent of total billed charges,,,,,,,,,95.57,,,percent of total billed charges,,,52.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,95.57,,,percent of total billed charges,,,49.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.65,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.11,,,percent of total billed charges,,
MORPHINE SULF PF 5 MG/10 ML,2500018652,CDM,636,RC,J2274,HCPCS,641602010,NDC,,,,outpatient,facility,10,UN,95.57,95.57,7.65,618.77,,55.81,,,percent of total billed charges,,,18.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,95.57,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,34.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,86.01,,,percent of total billed charges,,,,,,,,,95.57,,,percent of total billed charges,,,64.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.83,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.63,,,percent of total billed charges,,,36.2,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,95.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,95.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.65,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,95.57,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,,,,,,,95.57,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,10.88,,,fee schedule,,,95.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,95.57,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,67.11,,,percent of total billed charges,,
MORPHINE SULF PF 5 MG/10 ML,2500018652,CDM,636,RC,J2274,HCPCS,641602010,NDC,435,EAPG,,outpatient,facility,10,UN,95.57,95.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NALOXONE HCL 0.4 MG/ML AMP,2500018661,CDM,636,RC,J2310,HCPCS,641613225,NDC,,,,inpatient,facility,1,ML,19.8,19.8,1.58,19.8,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,19.8,,,percent of total billed charges,,,10.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.9,,,percent of total billed charges,,
NALOXONE HCL 0.4 MG/ML AMP,2500018661,CDM,636,RC,J2310,HCPCS,641613225,NDC,,,,outpatient,facility,1,ML,19.8,19.8,1.58,618.77,,11.56,,,percent of total billed charges,,,3.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,19.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,17.82,,,percent of total billed charges,,,,,,,,,19.8,,,percent of total billed charges,,,13.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.32,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.05,,,percent of total billed charges,,,7.5,,,percent of total billed charges,,,10.25,,,percent of total billed charges,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,19.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.58,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,19.8,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,9.69,,,fee schedule,,,19.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,13.9,,,percent of total billed charges,,
NALOXONE HCL 0.4 MG/ML AMP,2500018661,CDM,636,RC,J2310,HCPCS,641613225,NDC,435,EAPG,,outpatient,facility,1,ML,19.8,19.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CL 40 MEQ/100 ML IV,2500018673,CDM,636,RC,J3480,HCPCS,990707726,NDC,,,,inpatient,facility,100,ML,17.66,17.66,1.41,17.66,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.89,,,percent of total billed charges,,,,,,,,,17.66,,,percent of total billed charges,,,9.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.4,,,percent of total billed charges,,
POTASSIUM CL 40 MEQ/100 ML IV,2500018673,CDM,636,RC,J3480,HCPCS,990707726,NDC,,,,outpatient,facility,100,ML,17.66,17.66,0.11,618.77,,10.31,,,percent of total billed charges,,,3.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,17.66,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,15.89,,,percent of total billed charges,,,,,,,,,17.66,,,percent of total billed charges,,,11.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.42,,,percent of total billed charges,,,6.69,,,percent of total billed charges,,,9.15,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,17.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.41,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,,,,,,,17.66,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,17.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,17.66,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,12.4,,,percent of total billed charges,,
POTASSIUM CL 40 MEQ/100 ML IV,2500018673,CDM,636,RC,J3480,HCPCS,990707726,NDC,999,EAPG,,outpatient,facility,100,ML,17.66,17.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GALANTAMINE HBR 4 MG TAB,2500018690,CDM,637,RC,7043600406,NDC,,,,,,inpatient,facility,4,UN,10.49,10.49,0.84,10.49,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,10.49,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.37,,,percent of total billed charges,,
GALANTAMINE HBR 4 MG TAB,2500018690,CDM,637,RC,7043600406,NDC,,,,,,outpatient,facility,4,UN,10.49,10.49,0.84,618.77,,6.13,,,percent of total billed charges,,,2.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.49,,,percent of total billed charges,,,9.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,9.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,9.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.44,,,percent of total billed charges,,,,,,,,,10.49,,,percent of total billed charges,,,7.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.06,,,percent of total billed charges,,,,,,,,,,,,,,,5.66,,,percent of total billed charges,,,5.66,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.97,,,percent of total billed charges,,,3.97,,,percent of total billed charges,,,5.43,,,percent of total billed charges,,,,,,,,,,,,,,,2.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.88,,,percent of total billed charges,,,3.88,,,percent of total billed charges,,,10.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.84,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,,,,,,,10.49,,,fee schedule,,,9.76,,,percent of total billed charges,,,,,,,,,,,,,,,9.76,,,percent of total billed charges,,,9.76,,,percent of total billed charges,,,9.76,,,percent of total billed charges,,,7.87,,,percent of total billed charges,,,10.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.49,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.37,,,percent of total billed charges,,
GALANTAMINE HBR 4 MG TAB,2500018690,CDM,637,RC,7043600406,NDC,999,EAPG,,,,outpatient,facility,4,UN,10.49,10.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VORICONAZOLE 200 MG INJ,2500018800,CDM,636,RC,J3465,HCPCS,781341694,NDC,,,,inpatient,facility,200,GR,503.51,503.51,40.28,503.51,,,,,,,,,,,,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.16,,,percent of total billed charges,,,,,,,,,503.51,,,percent of total billed charges,,,278.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,459.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,503.51,,,percent of total billed charges,,,262.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.28,,,percent of total billed charges,,,503.51,,,percent of total billed charges,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,353.56,,,percent of total billed charges,,
VORICONAZOLE 200 MG INJ,2500018800,CDM,636,RC,J3465,HCPCS,781341694,NDC,,,,outpatient,facility,200,GR,503.51,503.51,0.73,618.77,,294.05,,,percent of total billed charges,,,98.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,503.51,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,184.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,453.16,,,percent of total billed charges,,,,,,,,,503.51,,,percent of total billed charges,,,340.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.7,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,fee schedule,,,1.16,,,fee schedule,,,,,,,,,618.77,,,per diem,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,262.53,,,percent of total billed charges,,,503.51,,,percent of total billed charges,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,382.67,,,percent of total billed charges,,,190.73,,,percent of total billed charges,,,260.77,,,percent of total billed charges,,,,,,,,,,,,,,,100.7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,503.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,503.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.28,,,percent of total billed charges,,,503.51,,,percent of total billed charges,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,503.51,,,percent of total billed charges,,,503.51,,,percent of total billed charges,,,,,,,,,503.51,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.73,,,fee schedule,,,503.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,503.51,,,percent of total billed charges,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,353.56,,,percent of total billed charges,,
VORICONAZOLE 200 MG INJ,2500018800,CDM,636,RC,J3465,HCPCS,781341694,NDC,435,EAPG,,outpatient,facility,200,GR,503.51,503.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VORICONAZOLE 200 MG TABLET,2500018803,CDM,637,RC,2724106303,NDC,,,,,,inpatient,facility,200,UN,262.42,262.42,20.99,262.42,,,,,,,,,,,,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.18,,,percent of total billed charges,,,,,,,,,262.42,,,percent of total billed charges,,,145.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,262.42,,,percent of total billed charges,,,136.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.99,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.27,,,percent of total billed charges,,
VORICONAZOLE 200 MG TABLET,2500018803,CDM,637,RC,2724106303,NDC,,,,,,outpatient,facility,200,UN,262.42,262.42,20.99,618.77,,153.25,,,percent of total billed charges,,,51.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,262.42,,,percent of total billed charges,,,231.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,231.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,231.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,96.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,236.18,,,percent of total billed charges,,,,,,,,,262.42,,,percent of total billed charges,,,177.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.54,,,percent of total billed charges,,,,,,,,,,,,,,,141.71,,,percent of total billed charges,,,141.71,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,136.83,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.44,,,percent of total billed charges,,,99.4,,,percent of total billed charges,,,135.91,,,percent of total billed charges,,,,,,,,,,,,,,,52.48,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,97.1,,,percent of total billed charges,,,97.1,,,percent of total billed charges,,,262.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,262.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.99,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,262.42,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,,,,,,,262.42,,,fee schedule,,,244.1,,,percent of total billed charges,,,,,,,,,,,,,,,244.1,,,percent of total billed charges,,,244.1,,,percent of total billed charges,,,244.1,,,percent of total billed charges,,,196.81,,,percent of total billed charges,,,262.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,262.42,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,184.27,,,percent of total billed charges,,
VORICONAZOLE 200 MG TABLET,2500018803,CDM,637,RC,2724106303,NDC,999,EAPG,,,,outpatient,facility,200,UN,262.42,262.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT EMTRICTB/TENOFVR/RALTEGRVR,2500018813,CDM,637,RC,4238595330,NDC,,,,,,inpatient,facility,1,UN,1099.69,1099.69,87.98,1099.69,,,,,,,,,,,,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,989.72,,,percent of total billed charges,,,,,,,,,1099.69,,,percent of total billed charges,,,608.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1003.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,1099.69,,,percent of total billed charges,,,573.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.98,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,772.2,,,percent of total billed charges,,
KIT EMTRICTB/TENOFVR/RALTEGRVR,2500018813,CDM,637,RC,4238595330,NDC,,,,,,outpatient,facility,1,UN,1099.69,1099.69,87.98,1099.69,,642.22,,,percent of total billed charges,,,214.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1099.69,,,percent of total billed charges,,,968.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,968.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,968.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,402.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,989.72,,,percent of total billed charges,,,,,,,,,1099.69,,,percent of total billed charges,,,744.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.56,,,percent of total billed charges,,,,,,,,,,,,,,,593.83,,,percent of total billed charges,,,593.83,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,573.38,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,835.76,,,percent of total billed charges,,,416.56,,,percent of total billed charges,,,569.53,,,percent of total billed charges,,,,,,,,,,,,,,,219.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,406.89,,,percent of total billed charges,,,406.89,,,percent of total billed charges,,,1099.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1099.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,87.98,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,1099.69,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,,,,,,,1099.69,,,fee schedule,,,1022.93,,,percent of total billed charges,,,,,,,,,,,,,,,1022.93,,,percent of total billed charges,,,1022.93,,,percent of total billed charges,,,1022.93,,,percent of total billed charges,,,824.77,,,percent of total billed charges,,,1099.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1099.69,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,549.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,772.2,,,percent of total billed charges,,
KIT EMTRICTB/TENOFVR/RALTEGRVR,2500018813,CDM,637,RC,4238595330,NDC,999,EAPG,,,,outpatient,facility,1,UN,1099.69,1099.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EMTRICITAB/TENOF 200/300MG TAB,2500018815,CDM,637,RC,4238595330,NDC,,,,,,inpatient,facility,1,UN,231.03,231.03,18.48,231.03,,,,,,,,,,,,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.93,,,percent of total billed charges,,,,,,,,,231.03,,,percent of total billed charges,,,127.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,231.03,,,percent of total billed charges,,,120.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.23,,,percent of total billed charges,,
EMTRICITAB/TENOF 200/300MG TAB,2500018815,CDM,637,RC,4238595330,NDC,,,,,,outpatient,facility,1,UN,231.03,231.03,18.48,618.77,,134.92,,,percent of total billed charges,,,45.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,231.03,,,percent of total billed charges,,,203.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,203.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,203.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,84.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,207.93,,,percent of total billed charges,,,,,,,,,231.03,,,percent of total billed charges,,,156.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.43,,,percent of total billed charges,,,,,,,,,,,,,,,124.76,,,percent of total billed charges,,,124.76,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,120.46,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.58,,,percent of total billed charges,,,87.51,,,percent of total billed charges,,,119.65,,,percent of total billed charges,,,,,,,,,,,,,,,46.21,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,85.48,,,percent of total billed charges,,,85.48,,,percent of total billed charges,,,231.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,231.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.48,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,231.03,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,,,,,,,231.03,,,fee schedule,,,214.9,,,percent of total billed charges,,,,,,,,,,,,,,,214.9,,,percent of total billed charges,,,214.9,,,percent of total billed charges,,,214.9,,,percent of total billed charges,,,173.27,,,percent of total billed charges,,,231.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,231.03,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,162.23,,,percent of total billed charges,,
EMTRICITAB/TENOF 200/300MG TAB,2500018815,CDM,637,RC,4238595330,NDC,999,EAPG,,,,outpatient,facility,1,UN,231.03,231.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ELVITEGR/COBCST/EMTR/TENOF TAB,2500018816,CDM,637,RC,6195819011,NDC,,,,,,inpatient,facility,1,UN,437.94,437.94,35.04,437.94,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,394.15,,,percent of total billed charges,,,,,,,,,437.94,,,percent of total billed charges,,,242.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,399.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,228.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.04,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.52,,,percent of total billed charges,,
ELVITEGR/COBCST/EMTR/TENOF TAB,2500018816,CDM,637,RC,6195819011,NDC,,,,,,outpatient,facility,1,UN,437.94,437.94,35.04,618.77,,255.76,,,percent of total billed charges,,,85.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,437.94,,,percent of total billed charges,,,385.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,385.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,385.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,160.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,394.15,,,percent of total billed charges,,,,,,,,,437.94,,,percent of total billed charges,,,296.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.34,,,percent of total billed charges,,,,,,,,,,,,,,,236.49,,,percent of total billed charges,,,236.49,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,228.34,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.83,,,percent of total billed charges,,,165.89,,,percent of total billed charges,,,226.81,,,percent of total billed charges,,,,,,,,,,,,,,,87.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,162.04,,,percent of total billed charges,,,162.04,,,percent of total billed charges,,,437.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,437.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.04,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,437.94,,,fee schedule,,,407.37,,,percent of total billed charges,,,,,,,,,,,,,,,407.37,,,percent of total billed charges,,,407.37,,,percent of total billed charges,,,407.37,,,percent of total billed charges,,,328.45,,,percent of total billed charges,,,437.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,307.52,,,percent of total billed charges,,
ELVITEGR/COBCST/EMTR/TENOF TAB,2500018816,CDM,637,RC,6195819011,NDC,999,EAPG,,,,outpatient,facility,1,UN,437.94,437.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ERTAPENEM  SOD PER 1 GM,2500018820,CDM,636,RC,J1335,HCPCS,4202322110,NDC,,,,inpatient,facility,1000,UN,386.33,386.33,30.91,386.33,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,347.7,,,percent of total billed charges,,,,,,,,,386.33,,,percent of total billed charges,,,213.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,201.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.91,,,percent of total billed charges,,,386.33,,,percent of total billed charges,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,271.28,,,percent of total billed charges,,
ERTAPENEM  SOD PER 1 GM,2500018820,CDM,636,RC,J1335,HCPCS,4202322110,NDC,,,,outpatient,facility,1000,UN,386.33,386.33,11.14,618.77,,225.62,,,percent of total billed charges,,,75.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,386.33,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,141.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,347.7,,,percent of total billed charges,,,,,,,,,386.33,,,percent of total billed charges,,,261.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,201.43,,,percent of total billed charges,,,386.33,,,percent of total billed charges,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,293.61,,,percent of total billed charges,,,146.34,,,percent of total billed charges,,,200.08,,,percent of total billed charges,,,,,,,,,,,,,,,77.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,386.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,386.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.91,,,percent of total billed charges,,,386.33,,,percent of total billed charges,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,386.33,,,percent of total billed charges,,,,,,,,,386.33,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,11.14,,,fee schedule,,,386.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,386.33,,,percent of total billed charges,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,271.28,,,percent of total billed charges,,
ERTAPENEM  SOD PER 1 GM,2500018820,CDM,636,RC,J1335,HCPCS,4202322110,NDC,999,EAPG,,outpatient,facility,1000,UN,386.33,386.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROMORPHONE 0.2MG/ML 30MLPCA,2500018840,CDM,636,RC,J1171,HCPCS,6155316141,NDC,,,,inpatient,facility,30,ML,22.54,22.54,1.8,22.54,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,,,,,,,22.54,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,11.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.83,,,percent of total billed charges,,
HYDROMORPHONE 0.2MG/ML 30MLPCA,2500018840,CDM,636,RC,J1171,HCPCS,6155316141,NDC,,,,outpatient,facility,30,ML,22.54,22.54,1.8,618.77,,13.16,,,percent of total billed charges,,,,,,,,,22.54,,,percent of total billed charges,,,19.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,19.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,19.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,20.29,,,percent of total billed charges,,,,,,,,,22.54,,,percent of total billed charges,,,15.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.31,,,percent of total billed charges,,,,,,,,,,,,,,,12.17,,,percent of total billed charges,,,12.17,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.75,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.13,,,percent of total billed charges,,,8.54,,,percent of total billed charges,,,11.67,,,percent of total billed charges,,,,,,,,,,,,,,,4.51,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.34,,,percent of total billed charges,,,8.34,,,percent of total billed charges,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,22.54,,,fee schedule,,,20.97,,,percent of total billed charges,,,,,,,,,,,,,,,20.97,,,percent of total billed charges,,,20.97,,,percent of total billed charges,,,20.97,,,percent of total billed charges,,,16.91,,,percent of total billed charges,,,22.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,22.54,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,15.83,,,percent of total billed charges,,
HYDROMORPHONE 0.2MG/ML 30MLPCA,2500018840,CDM,636,RC,J1171,HCPCS,6155316141,NDC,791,APC,,outpatient,facility,30,ML,22.54,22.54,0.09,8.25,,,,,,,,0.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,8.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.13,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.1,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,
HYDROMORPHONE 0.2MG/ML 30MLPCA,2500018840,CDM,636,RC,J1171,HCPCS,6155316141,NDC,999,EAPG,,outpatient,facility,30,ML,22.54,22.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARIPIPRAZOLE 10 MG TAB,2500018894,CDM,637,RC,6516289803,NDC,,,,,,inpatient,facility,10,UN,105.86,105.86,8.47,105.86,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.27,,,percent of total billed charges,,,,,,,,,105.86,,,percent of total billed charges,,,58.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,55.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.47,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.33,,,percent of total billed charges,,
ARIPIPRAZOLE 10 MG TAB,2500018894,CDM,637,RC,6516289803,NDC,,,,,,outpatient,facility,10,UN,105.86,105.86,8.47,618.77,,61.82,,,percent of total billed charges,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,105.86,,,percent of total billed charges,,,93.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,93.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,93.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,38.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,95.27,,,percent of total billed charges,,,,,,,,,105.86,,,percent of total billed charges,,,71.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.3,,,percent of total billed charges,,,,,,,,,,,,,,,57.16,,,percent of total billed charges,,,57.16,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.2,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.45,,,percent of total billed charges,,,40.1,,,percent of total billed charges,,,54.82,,,percent of total billed charges,,,,,,,,,,,,,,,21.17,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,39.17,,,percent of total billed charges,,,39.17,,,percent of total billed charges,,,105.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,105.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.47,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,105.86,,,fee schedule,,,98.47,,,percent of total billed charges,,,,,,,,,,,,,,,98.47,,,percent of total billed charges,,,98.47,,,percent of total billed charges,,,98.47,,,percent of total billed charges,,,79.39,,,percent of total billed charges,,,105.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,74.33,,,percent of total billed charges,,
ARIPIPRAZOLE 10 MG TAB,2500018894,CDM,637,RC,6516289803,NDC,999,EAPG,,,,outpatient,facility,10,UN,105.86,105.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARIPIPRAZOLE 5 MG TAB,2500018896,CDM,637,RC,6516289709,NDC,,,,,,inpatient,facility,5,UN,105.86,105.86,8.47,105.86,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.27,,,percent of total billed charges,,,,,,,,,105.86,,,percent of total billed charges,,,58.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,55.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.47,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.33,,,percent of total billed charges,,
ARIPIPRAZOLE 5 MG TAB,2500018896,CDM,637,RC,6516289709,NDC,,,,,,outpatient,facility,5,UN,105.86,105.86,8.47,618.77,,61.82,,,percent of total billed charges,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,105.86,,,percent of total billed charges,,,93.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,93.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,93.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,38.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,95.27,,,percent of total billed charges,,,,,,,,,105.86,,,percent of total billed charges,,,71.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.3,,,percent of total billed charges,,,,,,,,,,,,,,,57.16,,,percent of total billed charges,,,57.16,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.2,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.45,,,percent of total billed charges,,,40.1,,,percent of total billed charges,,,54.82,,,percent of total billed charges,,,,,,,,,,,,,,,21.17,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,39.17,,,percent of total billed charges,,,39.17,,,percent of total billed charges,,,105.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,105.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.47,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,105.86,,,fee schedule,,,98.47,,,percent of total billed charges,,,,,,,,,,,,,,,98.47,,,percent of total billed charges,,,98.47,,,percent of total billed charges,,,98.47,,,percent of total billed charges,,,79.39,,,percent of total billed charges,,,105.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,74.33,,,percent of total billed charges,,
ARIPIPRAZOLE 5 MG TAB,2500018896,CDM,637,RC,6516289709,NDC,999,EAPG,,,,outpatient,facility,5,UN,105.86,105.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARIPIPRAZOLE 2 MG TAB,2500018897,CDM,637,RC,6516289603,NDC,,,,,,inpatient,facility,2,UN,105.86,105.86,8.47,105.86,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.27,,,percent of total billed charges,,,,,,,,,105.86,,,percent of total billed charges,,,58.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,55.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.47,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.33,,,percent of total billed charges,,
ARIPIPRAZOLE 2 MG TAB,2500018897,CDM,637,RC,6516289603,NDC,,,,,,outpatient,facility,2,UN,105.86,105.86,8.47,618.77,,61.82,,,percent of total billed charges,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,105.86,,,percent of total billed charges,,,93.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,93.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,93.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,38.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,95.27,,,percent of total billed charges,,,,,,,,,105.86,,,percent of total billed charges,,,71.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.3,,,percent of total billed charges,,,,,,,,,,,,,,,57.16,,,percent of total billed charges,,,57.16,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.2,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.45,,,percent of total billed charges,,,40.1,,,percent of total billed charges,,,54.82,,,percent of total billed charges,,,,,,,,,,,,,,,21.17,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,39.17,,,percent of total billed charges,,,39.17,,,percent of total billed charges,,,105.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,105.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.47,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,105.86,,,fee schedule,,,98.47,,,percent of total billed charges,,,,,,,,,,,,,,,98.47,,,percent of total billed charges,,,98.47,,,percent of total billed charges,,,98.47,,,percent of total billed charges,,,79.39,,,percent of total billed charges,,,105.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,74.33,,,percent of total billed charges,,
ARIPIPRAZOLE 2 MG TAB,2500018897,CDM,637,RC,6516289603,NDC,999,EAPG,,,,outpatient,facility,2,UN,105.86,105.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FONDAPARINUX 2.5 MG INJ,2500018900,CDM,636,RC,J1652,HCPCS,5515023010,NDC,,,,inpatient,facility,0.5,UN,118.8,118.8,9.5,118.8,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.92,,,percent of total billed charges,,,,,,,,,118.8,,,percent of total billed charges,,,65.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,61.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.42,,,percent of total billed charges,,
FONDAPARINUX 2.5 MG INJ,2500018900,CDM,636,RC,J1652,HCPCS,5515023010,NDC,,,,outpatient,facility,0.5,UN,118.8,118.8,1.12,618.77,,69.38,,,percent of total billed charges,,,23.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,118.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,43.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,106.92,,,percent of total billed charges,,,,,,,,,118.8,,,percent of total billed charges,,,80.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.94,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.29,,,percent of total billed charges,,,45,,,percent of total billed charges,,,61.53,,,percent of total billed charges,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,118.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,118.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.5,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,118.8,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.12,,,fee schedule,,,118.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,118.8,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,83.42,,,percent of total billed charges,,
FONDAPARINUX 2.5 MG INJ,2500018900,CDM,636,RC,J1652,HCPCS,5515023010,NDC,496,EAPG,,outpatient,facility,0.5,UN,118.8,118.8,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FORMOTEROL 20 MCG NEB,2500018904,CDM,637,RC,J7606,HCPCS,4950260561,NDC,,,,inpatient,facility,2,UN,64.24,64.24,5.14,64.24,,,,,,,,,,,,,,64.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.82,,,percent of total billed charges,,,,,,,,,64.24,,,percent of total billed charges,,,35.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.24,,,percent of total billed charges,,,,,,,,,,,,,,,64.24,,,percent of total billed charges,,,33.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.14,,,percent of total billed charges,,,64.24,,,percent of total billed charges,,,64.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.11,,,percent of total billed charges,,
FORMOTEROL 20 MCG NEB,2500018904,CDM,637,RC,J7606,HCPCS,4950260561,NDC,,,,outpatient,facility,2,UN,64.24,64.24,2.38,618.77,,37.52,,,percent of total billed charges,,,12.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,64.24,,,percent of total billed charges,,,3.72,,,fee schedule,,,3.59,,,fee schedule,,,,,,,,,3.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,64.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,23.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,57.82,,,percent of total billed charges,,,,,,,,,64.24,,,percent of total billed charges,,,43.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.34,,,percent of total billed charges,,,,,,,,,,,,,,,4.1,,,fee schedule,,,4.1,,,fee schedule,,,,,,,,,618.77,,,per diem,,,64.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.49,,,percent of total billed charges,,,64.24,,,percent of total billed charges,,,64.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.82,,,percent of total billed charges,,,24.33,,,percent of total billed charges,,,33.27,,,percent of total billed charges,,,,,,,,,,,,,,,12.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,14.96,,,fee schedule,,,6.67,,,fee schedule,,,64.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,64.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.14,,,percent of total billed charges,,,64.24,,,percent of total billed charges,,,64.24,,,percent of total billed charges,,,,,,,,,,,,,,,64.24,,,percent of total billed charges,,,64.24,,,percent of total billed charges,,,,,,,,,2.38,,,fee schedule,,,7.12,,,fee schedule,,,,,,,,,,,,,,,6.26,,,fee schedule,,,8.35,,,fee schedule,,,4.63,,,fee schedule,,,3.27,,,fee schedule,,,64.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,64.24,,,percent of total billed charges,,,64.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,45.11,,,percent of total billed charges,,
FORMOTEROL 20 MCG NEB,2500018904,CDM,637,RC,J7606,HCPCS,4950260561,NDC,999,EAPG,,outpatient,facility,2,UN,64.24,64.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 4  CREAM 5 GM,2500018910,CDM,637,RC,2435770106,NDC,,,,,,inpatient,facility,5,UN,11.55,11.55,0.92,11.55,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.4,,,percent of total billed charges,,,,,,,,,11.55,,,percent of total billed charges,,,6.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.11,,,percent of total billed charges,,
LIDOCAINE 4  CREAM 5 GM,2500018910,CDM,637,RC,2435770106,NDC,,,,,,outpatient,facility,5,UN,11.55,11.55,0.92,618.77,,6.75,,,percent of total billed charges,,,2.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.55,,,percent of total billed charges,,,10.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,10.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,10.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.4,,,percent of total billed charges,,,,,,,,,11.55,,,percent of total billed charges,,,7.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.87,,,percent of total billed charges,,,,,,,,,,,,,,,6.24,,,percent of total billed charges,,,6.24,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,5.98,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.27,,,percent of total billed charges,,,4.27,,,percent of total billed charges,,,11.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,11.55,,,fee schedule,,,10.74,,,percent of total billed charges,,,,,,,,,,,,,,,10.74,,,percent of total billed charges,,,10.74,,,percent of total billed charges,,,10.74,,,percent of total billed charges,,,8.66,,,percent of total billed charges,,,11.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.11,,,percent of total billed charges,,
LIDOCAINE 4  CREAM 5 GM,2500018910,CDM,637,RC,2435770106,NDC,999,EAPG,,,,outpatient,facility,5,UN,11.55,11.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE D5W 2 GM 250 ML,2500018912,CDM,636,RC,J2002,HCPCS,264959820,NDC,,,,inpatient,facility,250,UN,25.34,25.34,2.03,25.34,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.81,,,percent of total billed charges,,,,,,,,,25.34,,,percent of total billed charges,,,14.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,13.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,
LIDOCAINE D5W 2 GM 250 ML,2500018912,CDM,636,RC,J2002,HCPCS,264959820,NDC,,,,outpatient,facility,250,UN,25.34,25.34,2.03,618.77,,14.8,,,percent of total billed charges,,,,,,,,,25.34,,,percent of total billed charges,,,22.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,22.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,22.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22.81,,,percent of total billed charges,,,,,,,,,25.34,,,percent of total billed charges,,,17.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.46,,,percent of total billed charges,,,,,,,,,,,,,,,13.68,,,percent of total billed charges,,,13.68,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.21,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.26,,,percent of total billed charges,,,9.6,,,percent of total billed charges,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,9.38,,,percent of total billed charges,,,9.38,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,25.34,,,fee schedule,,,23.57,,,percent of total billed charges,,,,,,,,,,,,,,,23.57,,,percent of total billed charges,,,23.57,,,percent of total billed charges,,,23.57,,,percent of total billed charges,,,19,,,percent of total billed charges,,,25.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,25.34,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.67,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.79,,,percent of total billed charges,,
LIDOCAINE D5W 2 GM 250 ML,2500018912,CDM,636,RC,J2002,HCPCS,264959820,NDC,795,APC,,outpatient,facility,250,UN,25.34,25.34,9.27,9.27,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LIDOCAINE D5W 2 GM 250 ML,2500018912,CDM,636,RC,J2002,HCPCS,264959820,NDC,999,EAPG,,outpatient,facility,250,UN,25.34,25.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESCITALOPRAM 10 MG TAB,2500018950,CDM,637,RC,904642661,NDC,,,,,,inpatient,facility,10,UN,14.45,14.45,1.16,14.45,,,,,,,,,,,,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13,,,percent of total billed charges,,,,,,,,,14.45,,,percent of total billed charges,,,8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,14.45,,,percent of total billed charges,,,7.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.15,,,percent of total billed charges,,
ESCITALOPRAM 10 MG TAB,2500018950,CDM,637,RC,904642661,NDC,,,,,,outpatient,facility,10,UN,14.45,14.45,1.16,618.77,,8.44,,,percent of total billed charges,,,2.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.45,,,percent of total billed charges,,,12.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13,,,percent of total billed charges,,,,,,,,,14.45,,,percent of total billed charges,,,9.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.1,,,percent of total billed charges,,,,,,,,,,,,,,,7.8,,,percent of total billed charges,,,7.8,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.53,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.98,,,percent of total billed charges,,,5.47,,,percent of total billed charges,,,7.48,,,percent of total billed charges,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.35,,,percent of total billed charges,,,5.35,,,percent of total billed charges,,,14.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.16,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,14.45,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,,,,,,,14.45,,,fee schedule,,,13.44,,,percent of total billed charges,,,,,,,,,,,,,,,13.44,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,10.84,,,percent of total billed charges,,,14.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.45,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.15,,,percent of total billed charges,,
ESCITALOPRAM 10 MG TAB,2500018950,CDM,637,RC,904642661,NDC,999,EAPG,,,,outpatient,facility,10,UN,14.45,14.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESCITALOPRAM 5 MG TAB,2500018953,CDM,637,RC,4354728010,NDC,,,,,,inpatient,facility,5,UN,13.69,13.69,1.1,13.69,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.32,,,percent of total billed charges,,,,,,,,,13.69,,,percent of total billed charges,,,7.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,7.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.61,,,percent of total billed charges,,
ESCITALOPRAM 5 MG TAB,2500018953,CDM,637,RC,4354728010,NDC,,,,,,outpatient,facility,5,UN,13.69,13.69,1.1,618.77,,7.99,,,percent of total billed charges,,,2.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.69,,,percent of total billed charges,,,12.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.32,,,percent of total billed charges,,,,,,,,,13.69,,,percent of total billed charges,,,9.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.51,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.14,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.4,,,percent of total billed charges,,,5.19,,,percent of total billed charges,,,7.09,,,percent of total billed charges,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.07,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,13.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,13.69,,,fee schedule,,,12.73,,,percent of total billed charges,,,,,,,,,,,,,,,12.73,,,percent of total billed charges,,,12.73,,,percent of total billed charges,,,12.73,,,percent of total billed charges,,,10.27,,,percent of total billed charges,,,13.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.61,,,percent of total billed charges,,
ESCITALOPRAM 5 MG TAB,2500018953,CDM,637,RC,4354728010,NDC,999,EAPG,,,,outpatient,facility,5,UN,13.69,13.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EZETIMIBE 10 MG TAB,2500019010,CDM,637,RC,6787749005,NDC,,,,,,inpatient,facility,10,UN,33.92,33.92,2.71,33.92,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.53,,,percent of total billed charges,,,,,,,,,33.92,,,percent of total billed charges,,,18.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,17.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.82,,,percent of total billed charges,,
EZETIMIBE 10 MG TAB,2500019010,CDM,637,RC,6787749005,NDC,,,,,,outpatient,facility,10,UN,33.92,33.92,2.71,618.77,,19.81,,,percent of total billed charges,,,6.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,33.92,,,percent of total billed charges,,,29.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,29.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,29.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,12.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,30.53,,,percent of total billed charges,,,,,,,,,33.92,,,percent of total billed charges,,,22.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.05,,,percent of total billed charges,,,,,,,,,,,,,,,18.32,,,percent of total billed charges,,,18.32,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.69,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.78,,,percent of total billed charges,,,12.85,,,percent of total billed charges,,,17.57,,,percent of total billed charges,,,,,,,,,,,,,,,6.78,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,12.55,,,percent of total billed charges,,,12.55,,,percent of total billed charges,,,33.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.71,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,,,,,,,33.92,,,fee schedule,,,31.55,,,percent of total billed charges,,,,,,,,,,,,,,,31.55,,,percent of total billed charges,,,31.55,,,percent of total billed charges,,,31.55,,,percent of total billed charges,,,25.44,,,percent of total billed charges,,,33.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,33.92,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,23.82,,,percent of total billed charges,,
EZETIMIBE 10 MG TAB,2500019010,CDM,637,RC,6787749005,NDC,999,EAPG,,,,outpatient,facility,10,UN,33.92,33.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSULIN HUMAN 70/30 1 UNIT INJ,2500019041,CDM,637,RC,J1815,HCPCS,2871501,NDC,,,,inpatient,facility,0.01,UN,0.49,0.49,0.04,0.49,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,
INSULIN HUMAN 70/30 1 UNIT INJ,2500019041,CDM,637,RC,J1815,HCPCS,2871501,NDC,,,,outpatient,facility,0.01,UN,0.49,0.49,0.04,618.77,,0.29,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.49,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.44,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,0.49,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.49,,,fee schedule,,,0.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.34,,,percent of total billed charges,,
INSULIN HUMAN 70/30 1 UNIT INJ,2500019041,CDM,637,RC,J1815,HCPCS,2871501,NDC,496,EAPG,,outpatient,facility,0.01,UN,0.49,0.49,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSULIN HUMAN REG 1 UNIT INJ,2500019042,CDM,637,RC,J1815,HCPCS,2821501,NDC,,,,inpatient,facility,0.01,UN,0.13,0.13,0.01,0.13,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,0.13,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,
INSULIN HUMAN REG 1 UNIT INJ,2500019042,CDM,637,RC,J1815,HCPCS,2821501,NDC,,,,outpatient,facility,0.01,UN,0.13,0.13,0.01,618.77,,0.08,,,percent of total billed charges,,,0.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.12,,,percent of total billed charges,,,,,,,,,0.13,,,percent of total billed charges,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,0.05,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,0.13,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.13,,,fee schedule,,,0.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.13,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.09,,,percent of total billed charges,,
INSULIN HUMAN REG 1 UNIT INJ,2500019042,CDM,637,RC,J1815,HCPCS,2821501,NDC,496,EAPG,,outpatient,facility,0.01,UN,0.13,0.13,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSULIN HUMAN NPH 1 UNIT INJ,2500019044,CDM,637,RC,J1815,HCPCS,2831501,NDC,,,,inpatient,facility,0.01,UN,4.4,4.4,0.35,4.4,,,,,,,,,,,,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,4.4,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,4.4,,,percent of total billed charges,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.09,,,percent of total billed charges,,
INSULIN HUMAN NPH 1 UNIT INJ,2500019044,CDM,637,RC,J1815,HCPCS,2831501,NDC,,,,outpatient,facility,0.01,UN,4.4,4.4,0.35,618.77,,2.57,,,percent of total billed charges,,,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.4,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.96,,,percent of total billed charges,,,,,,,,,4.4,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.29,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.34,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,4.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.35,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,4.4,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,4.4,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.94,,,fee schedule,,,4.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.4,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.09,,,percent of total billed charges,,
INSULIN HUMAN NPH 1 UNIT INJ,2500019044,CDM,637,RC,J1815,HCPCS,2831501,NDC,496,EAPG,,outpatient,facility,0.01,UN,4.4,4.4,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSULIN GLARGINE 1 UNIT INJ,2500019088,CDM,637,RC,J1815,HCPCS,88222033,NDC,,,,inpatient,facility,0.01,UN,0.39,0.39,0.03,0.39,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,
INSULIN GLARGINE 1 UNIT INJ,2500019088,CDM,637,RC,J1815,HCPCS,88222033,NDC,,,,outpatient,facility,0.01,UN,0.39,0.39,0.03,618.77,,0.23,,,percent of total billed charges,,,0.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.39,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.35,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,0.39,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.39,,,fee schedule,,,0.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.27,,,percent of total billed charges,,
INSULIN GLARGINE 1 UNIT INJ,2500019088,CDM,637,RC,J1815,HCPCS,88222033,NDC,496,EAPG,,outpatient,facility,0.01,UN,0.39,0.39,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSULIN GLARGINE 3 ML INJPEN,2500019094,CDM,637,RC,J1815,HCPCS,88221905,NDC,,,,inpatient,facility,3,UN,63.62,63.62,5.09,63.62,,,,,,,,,,,,,,63.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.26,,,percent of total billed charges,,,,,,,,,63.62,,,percent of total billed charges,,,35.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.62,,,percent of total billed charges,,,,,,,,,,,,,,,63.62,,,percent of total billed charges,,,33.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.09,,,percent of total billed charges,,,63.62,,,percent of total billed charges,,,63.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.67,,,percent of total billed charges,,
INSULIN GLARGINE 3 ML INJPEN,2500019094,CDM,637,RC,J1815,HCPCS,88221905,NDC,,,,outpatient,facility,3,UN,63.62,63.62,0.94,618.77,,37.15,,,percent of total billed charges,,,12.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,63.62,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,63.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,23.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,57.26,,,percent of total billed charges,,,,,,,,,63.62,,,percent of total billed charges,,,43.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,63.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.17,,,percent of total billed charges,,,63.62,,,percent of total billed charges,,,63.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.35,,,percent of total billed charges,,,24.1,,,percent of total billed charges,,,32.95,,,percent of total billed charges,,,,,,,,,,,,,,,12.72,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,63.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,63.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.09,,,percent of total billed charges,,,63.62,,,percent of total billed charges,,,63.62,,,percent of total billed charges,,,,,,,,,,,,,,,63.62,,,percent of total billed charges,,,63.62,,,percent of total billed charges,,,,,,,,,63.62,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.94,,,fee schedule,,,63.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,63.62,,,percent of total billed charges,,,63.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,44.67,,,percent of total billed charges,,
INSULIN GLARGINE 3 ML INJPEN,2500019094,CDM,637,RC,J1815,HCPCS,88221905,NDC,496,EAPG,,outpatient,facility,3,UN,63.62,63.62,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSULIN ASPART 70/30 1 UNIT,2500019101,CDM,637,RC,J1815,HCPCS,7307020011,NDC,,,,inpatient,facility,0.01,UN,10.4,10.4,0.83,10.4,,,,,,,,,,,,,,10.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.36,,,percent of total billed charges,,,,,,,,,10.4,,,percent of total billed charges,,,5.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.4,,,percent of total billed charges,,,,,,,,,,,,,,,10.4,,,percent of total billed charges,,,5.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,10.4,,,percent of total billed charges,,,10.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.3,,,percent of total billed charges,,
INSULIN ASPART 70/30 1 UNIT,2500019101,CDM,637,RC,J1815,HCPCS,7307020011,NDC,,,,outpatient,facility,0.01,UN,10.4,10.4,0.83,618.77,,6.07,,,percent of total billed charges,,,2.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.4,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,10.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.36,,,percent of total billed charges,,,,,,,,,10.4,,,percent of total billed charges,,,7.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,10.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.42,,,percent of total billed charges,,,10.4,,,percent of total billed charges,,,10.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.9,,,percent of total billed charges,,,3.94,,,percent of total billed charges,,,5.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,10.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.83,,,percent of total billed charges,,,10.4,,,percent of total billed charges,,,10.4,,,percent of total billed charges,,,,,,,,,,,,,,,10.4,,,percent of total billed charges,,,10.4,,,percent of total billed charges,,,,,,,,,10.4,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.94,,,fee schedule,,,10.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.4,,,percent of total billed charges,,,10.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.3,,,percent of total billed charges,,
INSULIN ASPART 70/30 1 UNIT,2500019101,CDM,637,RC,J1815,HCPCS,7307020011,NDC,496,EAPG,,outpatient,facility,0.01,UN,10.4,10.4,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSULIN HUMAN REG 100U/100ML,2500019104,CDM,637,RC,J1815,HCPCS,2821501,NDC,,,,inpatient,facility,100,UN,45.44,45.44,3.64,45.44,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.9,,,percent of total billed charges,,,,,,,,,45.44,,,percent of total billed charges,,,25.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,23.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.91,,,percent of total billed charges,,
INSULIN HUMAN REG 100U/100ML,2500019104,CDM,637,RC,J1815,HCPCS,2821501,NDC,,,,outpatient,facility,100,UN,45.44,45.44,0.94,618.77,,26.54,,,percent of total billed charges,,,8.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,45.44,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,40.9,,,percent of total billed charges,,,,,,,,,45.44,,,percent of total billed charges,,,30.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.69,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.53,,,percent of total billed charges,,,17.21,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,9.09,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,45.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,45.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.64,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,45.44,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.94,,,fee schedule,,,45.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,45.44,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,31.91,,,percent of total billed charges,,
INSULIN HUMAN REG 100U/100ML,2500019104,CDM,637,RC,J1815,HCPCS,2821501,NDC,496,EAPG,,outpatient,facility,100,UN,45.44,45.44,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.45  1000 ML,2500019150,CDM,258,RC,J7040,HCPCS,264780200,NDC,,,,inpatient,facility,1000,UN,12.87,12.87,1.03,12.87,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.58,,,percent of total billed charges,,,,,,,,,12.87,,,percent of total billed charges,,,7.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,6.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.04,,,percent of total billed charges,,
SOD CHLORIDE 0.45  1000 ML,2500019150,CDM,258,RC,J7040,HCPCS,264780200,NDC,,,,outpatient,facility,1000,UN,12.87,12.87,1.03,618.77,,7.52,,,percent of total billed charges,,,2.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,12.87,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.58,,,percent of total billed charges,,,,,,,,,12.87,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.71,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,4.88,,,percent of total billed charges,,,6.67,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,12.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.03,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,,,,,,,12.87,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.4,,,fee schedule,,,12.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,12.87,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.04,,,percent of total billed charges,,
SOD CHLORIDE 0.45  1000 ML,2500019150,CDM,258,RC,J7040,HCPCS,264780200,NDC,496,EAPG,,outpatient,facility,1000,UN,12.87,12.87,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHL 0.45 KCL 20MEQ 1000ML,2500019151,CDM,636,RC,J3480,HCPCS,338070434,NDC,,,,inpatient,facility,1000,UN,23.83,23.83,1.91,23.83,,,,,,,,,,,,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.45,,,percent of total billed charges,,,,,,,,,23.83,,,percent of total billed charges,,,13.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,23.83,,,percent of total billed charges,,,12.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,23.83,,,percent of total billed charges,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.73,,,percent of total billed charges,,
SOD CHL 0.45 KCL 20MEQ 1000ML,2500019151,CDM,636,RC,J3480,HCPCS,338070434,NDC,,,,outpatient,facility,1000,UN,23.83,23.83,0.11,618.77,,13.92,,,percent of total billed charges,,,4.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,23.83,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,21.45,,,percent of total billed charges,,,,,,,,,23.83,,,percent of total billed charges,,,16.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.42,,,percent of total billed charges,,,23.83,,,percent of total billed charges,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.11,,,percent of total billed charges,,,9.03,,,percent of total billed charges,,,12.34,,,percent of total billed charges,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,23.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.91,,,percent of total billed charges,,,23.83,,,percent of total billed charges,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,23.83,,,percent of total billed charges,,,23.83,,,percent of total billed charges,,,,,,,,,23.83,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,23.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,23.83,,,percent of total billed charges,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,16.73,,,percent of total billed charges,,
SOD CHL 0.45 KCL 20MEQ 1000ML,2500019151,CDM,636,RC,J3480,HCPCS,338070434,NDC,999,EAPG,,outpatient,facility,1000,UN,23.83,23.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPOT DIAGNOSTIC SYRINGE,2500019160,CDM,250,RC,,,,,,,,inpatient,facility,5,UN,97.35,97.35,7.79,97.35,,,,,,,,,,,,,,97.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.61,,,percent of total billed charges,,,,,,,,,97.35,,,percent of total billed charges,,,53.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.35,,,percent of total billed charges,,,,,,,,,,,,,,,97.35,,,percent of total billed charges,,,50.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,97.35,,,percent of total billed charges,,,97.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,97.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.36,,,percent of total billed charges,,
SPOT DIAGNOSTIC SYRINGE,2500019160,CDM,250,RC,,,,,,,,outpatient,facility,5,UN,97.35,97.35,7.79,618.77,,56.85,,,percent of total billed charges,,,18.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,97.35,,,percent of total billed charges,,,85.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,85.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,85.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,97.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,35.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,87.61,,,percent of total billed charges,,,,,,,,,97.35,,,percent of total billed charges,,,65.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,97.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.76,,,percent of total billed charges,,,97.35,,,percent of total billed charges,,,97.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.99,,,percent of total billed charges,,,36.88,,,percent of total billed charges,,,50.42,,,percent of total billed charges,,,,,,,,,,,,,,,19.47,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,38.94,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,97.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,97.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.79,,,percent of total billed charges,,,97.35,,,percent of total billed charges,,,97.35,,,percent of total billed charges,,,,,,,,,,,,,,,97.35,,,percent of total billed charges,,,97.35,,,percent of total billed charges,,,,,,,,,97.35,,,fee schedule,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,73.01,,,percent of total billed charges,,,97.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,97.35,,,percent of total billed charges,,,97.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.67,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,68.36,,,percent of total billed charges,,
SPOT DIAGNOSTIC SYRINGE,2500019160,CDM,250,RC,999,EAPG,,,,,,outpatient,facility,5,UN,97.35,97.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 2  20 ML INJ,2500019220,CDM,250,RC,J2003,HCPCS,5515025520,NDC,,,,inpatient,facility,20,UN,16.63,16.63,1.33,16.63,,,,,,,,,,,,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.97,,,percent of total billed charges,,,,,,,,,16.63,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,16.63,,,percent of total billed charges,,,8.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,
LIDOCAINE HCL 2  20 ML INJ,2500019220,CDM,250,RC,J2003,HCPCS,5515025520,NDC,,,,outpatient,facility,20,UN,16.63,16.63,1.33,618.77,,9.71,,,percent of total billed charges,,,3.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.63,,,percent of total billed charges,,,14.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,14.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,14.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,14.97,,,percent of total billed charges,,,,,,,,,16.63,,,percent of total billed charges,,,11.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.67,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.64,,,percent of total billed charges,,,6.3,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,3.33,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.15,,,percent of total billed charges,,,6.15,,,percent of total billed charges,,,16.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.33,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,16.63,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,,,,,,,16.63,,,fee schedule,,,15.47,,,percent of total billed charges,,,,,,,,,,,,,,,15.47,,,percent of total billed charges,,,15.47,,,percent of total billed charges,,,15.47,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,16.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.63,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.68,,,percent of total billed charges,,
LIDOCAINE HCL 2  20 ML INJ,2500019220,CDM,250,RC,J2003,HCPCS,5515025520,NDC,999,EAPG,,outpatient,facility,20,UN,16.63,16.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 2  5 ML INJ,2500019222,CDM,250,RC,J2003,HCPCS,6332349507,NDC,,,,inpatient,facility,5,ML,11.84,11.84,0.95,11.84,,,,,,,,,,,,,,11.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.66,,,percent of total billed charges,,,,,,,,,11.84,,,percent of total billed charges,,,6.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.84,,,percent of total billed charges,,,,,,,,,,,,,,,11.84,,,percent of total billed charges,,,6.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,11.84,,,percent of total billed charges,,,11.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.31,,,percent of total billed charges,,
LIDOCAINE HCL 2  5 ML INJ,2500019222,CDM,250,RC,J2003,HCPCS,6332349507,NDC,,,,outpatient,facility,5,ML,11.84,11.84,0.95,618.77,,6.91,,,percent of total billed charges,,,2.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.84,,,percent of total billed charges,,,10.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,10.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,10.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.66,,,percent of total billed charges,,,,,,,,,11.84,,,percent of total billed charges,,,8.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,11.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.17,,,percent of total billed charges,,,11.84,,,percent of total billed charges,,,11.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9,,,percent of total billed charges,,,4.48,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.38,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,11.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.95,,,percent of total billed charges,,,11.84,,,percent of total billed charges,,,11.84,,,percent of total billed charges,,,,,,,,,,,,,,,11.84,,,percent of total billed charges,,,11.84,,,percent of total billed charges,,,,,,,,,11.84,,,fee schedule,,,11.01,,,percent of total billed charges,,,,,,,,,,,,,,,11.01,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,8.88,,,percent of total billed charges,,,11.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.84,,,percent of total billed charges,,,11.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.31,,,percent of total billed charges,,
LIDOCAINE HCL 2  5 ML INJ,2500019222,CDM,250,RC,J2003,HCPCS,6332349507,NDC,999,EAPG,,outpatient,facility,5,ML,11.84,11.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RISPERIDONE 25 MG/2ML INJ KIT,2500019233,CDM,636,RC,J2794,HCPCS,5045830611,NDC,,,,inpatient,facility,25,UN,2028.05,2028.05,162.24,2028.05,,,,,,,,,,,,,,2028.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1825.24,,,percent of total billed charges,,,,,,,,,2028.05,,,percent of total billed charges,,,1122.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1850.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2028.05,,,percent of total billed charges,,,,,,,,,,,,,,,2028.05,,,percent of total billed charges,,,1057.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,405.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.24,,,percent of total billed charges,,,2028.05,,,percent of total billed charges,,,2028.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2028.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1424.1,,,percent of total billed charges,,
RISPERIDONE 25 MG/2ML INJ KIT,2500019233,CDM,636,RC,J2794,HCPCS,5045830611,NDC,,,,outpatient,facility,25,UN,2028.05,2028.05,7.91,2028.05,,1184.38,,,percent of total billed charges,,,,,,,,,2028.05,,,percent of total billed charges,,,14.37,,,fee schedule,,,13.85,,,fee schedule,,,,,,,,,13.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2028.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1825.24,,,percent of total billed charges,,,,,,,,,2028.05,,,percent of total billed charges,,,1373.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.54,,,percent of total billed charges,,,,,,,,,,,,,,,12.15,,,fee schedule,,,12.15,,,fee schedule,,,,,,,,,618.77,,,per diem,,,2028.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1057.43,,,percent of total billed charges,,,2028.05,,,percent of total billed charges,,,2028.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1541.32,,,percent of total billed charges,,,768.23,,,percent of total billed charges,,,1050.33,,,percent of total billed charges,,,,,,,,,,,,,,,405.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,25.58,,,fee schedule,,,11.4,,,fee schedule,,,,,,,,,,,,,,,162.24,,,percent of total billed charges,,,2028.05,,,percent of total billed charges,,,2028.05,,,percent of total billed charges,,,,,,,,,,,,,,,2028.05,,,percent of total billed charges,,,2028.05,,,percent of total billed charges,,,,,,,,,2028.05,,,fee schedule,,,12.17,,,fee schedule,,,,,,,,,,,,,,,10.7,,,fee schedule,,,14.27,,,fee schedule,,,7.91,,,fee schedule,,,12.63,,,fee schedule,,,2028.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2028.05,,,percent of total billed charges,,,2028.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1014.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1424.1,,,percent of total billed charges,,
RISPERIDONE 25 MG/2ML INJ KIT,2500019233,CDM,636,RC,J2794,HCPCS,5045830611,NDC,9125,APC,,outpatient,facility,25,UN,2028.05,2028.05,10.55,742.27,,,,,,,,11.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.1,,,fee schedule,,,,,,,,,742.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,10.99,,,fee schedule,,,11.54,,,fee schedule,,,,,,,,,10.99,,,fee schedule,,,10.99,,,fee schedule,,,11.54,,,fee schedule,,,,,,,,,,,,,,,15.94,,,fee schedule,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,10.55,,,fee schedule,,,11.76,,,fee schedule,,,11.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,10.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,11.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,10.99,,,fee schedule,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,10.99,,,fee schedule,,,11.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.3,,,fee schedule,,,10.99,,,fee schedule,,,11.43,,,fee schedule,,,10.99,,,fee schedule,,,,,,,,,10.99,,,fee schedule,,,,,,,,,10.99,,,fee schedule,,,,,,,,
RISPERIDONE 25 MG/2ML INJ KIT,2500019233,CDM,636,RC,J2794,HCPCS,5045830611,NDC,439,EAPG,,outpatient,facility,25,UN,2028.05,2028.05,767.47,1125.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.11,,,fee schedule,,,767.47,,,fee schedule,,,1000.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,767.47,,,fee schedule,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RISPERIDONE 50 MG/2ML INJ KIT,2500019235,CDM,636,RC,J2794,HCPCS,5045830811,NDC,,,,inpatient,facility,50,UN,4056.39,4056.39,324.51,4056.39,,,,,,,,,,,,,,4056.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3650.75,,,percent of total billed charges,,,,,,,,,4056.39,,,percent of total billed charges,,,2245.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3701.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4056.39,,,percent of total billed charges,,,,,,,,,,,,,,,4056.39,,,percent of total billed charges,,,2115,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,811.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,324.51,,,percent of total billed charges,,,4056.39,,,percent of total billed charges,,,4056.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4056.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2848.4,,,percent of total billed charges,,
RISPERIDONE 50 MG/2ML INJ KIT,2500019235,CDM,636,RC,J2794,HCPCS,5045830811,NDC,,,,outpatient,facility,50,UN,4056.39,4056.39,7.91,4056.39,,2368.93,,,percent of total billed charges,,,,,,,,,4056.39,,,percent of total billed charges,,,14.37,,,fee schedule,,,13.85,,,fee schedule,,,,,,,,,13.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4056.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3650.75,,,percent of total billed charges,,,,,,,,,4056.39,,,percent of total billed charges,,,2746.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3115.31,,,percent of total billed charges,,,,,,,,,,,,,,,12.15,,,fee schedule,,,12.15,,,fee schedule,,,,,,,,,618.77,,,per diem,,,4056.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2115,,,percent of total billed charges,,,4056.39,,,percent of total billed charges,,,4056.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3082.86,,,percent of total billed charges,,,1536.56,,,percent of total billed charges,,,2100.8,,,percent of total billed charges,,,,,,,,,,,,,,,811.28,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,25.58,,,fee schedule,,,11.4,,,fee schedule,,,,,,,,,,,,,,,324.51,,,percent of total billed charges,,,4056.39,,,percent of total billed charges,,,4056.39,,,percent of total billed charges,,,,,,,,,,,,,,,4056.39,,,percent of total billed charges,,,4056.39,,,percent of total billed charges,,,,,,,,,4056.39,,,fee schedule,,,12.17,,,fee schedule,,,,,,,,,,,,,,,10.7,,,fee schedule,,,14.27,,,fee schedule,,,7.91,,,fee schedule,,,12.63,,,fee schedule,,,4056.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4056.39,,,percent of total billed charges,,,4056.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2028.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2848.4,,,percent of total billed charges,,
RISPERIDONE 50 MG/2ML INJ KIT,2500019235,CDM,636,RC,J2794,HCPCS,5045830811,NDC,9125,APC,,outpatient,facility,50,UN,4056.39,4056.39,10.55,1484.64,,,,,,,,11.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.1,,,fee schedule,,,,,,,,,1484.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,10.99,,,fee schedule,,,11.54,,,fee schedule,,,,,,,,,10.99,,,fee schedule,,,10.99,,,fee schedule,,,11.54,,,fee schedule,,,,,,,,,,,,,,,15.94,,,fee schedule,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,10.55,,,fee schedule,,,11.76,,,fee schedule,,,11.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,10.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,11.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,10.99,,,fee schedule,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,10.99,,,fee schedule,,,11.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.3,,,fee schedule,,,10.99,,,fee schedule,,,11.43,,,fee schedule,,,10.99,,,fee schedule,,,,,,,,,10.99,,,fee schedule,,,,,,,,,10.99,,,fee schedule,,,,,,,,
RISPERIDONE 50 MG/2ML INJ KIT,2500019235,CDM,636,RC,J2794,HCPCS,5045830811,NDC,439,EAPG,,outpatient,facility,50,UN,4056.39,4056.39,767.47,1125.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.11,,,fee schedule,,,767.47,,,fee schedule,,,1000.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,767.47,,,fee schedule,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RISPERIDONE ODT 0.5 MG,2500019236,CDM,637,RC,5974601032,NDC,,,,,,inpatient,facility,0.5,UN,16.23,16.23,1.3,16.23,,,,,,,,,,,,,,16.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.61,,,percent of total billed charges,,,,,,,,,16.23,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.23,,,percent of total billed charges,,,,,,,,,,,,,,,16.23,,,percent of total billed charges,,,8.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,16.23,,,percent of total billed charges,,,16.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.4,,,percent of total billed charges,,
RISPERIDONE ODT 0.5 MG,2500019236,CDM,637,RC,5974601032,NDC,,,,,,outpatient,facility,0.5,UN,16.23,16.23,1.3,618.77,,9.48,,,percent of total billed charges,,,3.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.23,,,percent of total billed charges,,,14.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,14.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,14.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,14.61,,,percent of total billed charges,,,,,,,,,16.23,,,percent of total billed charges,,,10.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.46,,,percent of total billed charges,,,,,,,,,,,,,,,8.76,,,percent of total billed charges,,,8.76,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,16.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.46,,,percent of total billed charges,,,16.23,,,percent of total billed charges,,,16.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.33,,,percent of total billed charges,,,6.15,,,percent of total billed charges,,,8.41,,,percent of total billed charges,,,,,,,,,,,,,,,3.25,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.01,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,16.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.3,,,percent of total billed charges,,,16.23,,,percent of total billed charges,,,16.23,,,percent of total billed charges,,,,,,,,,,,,,,,16.23,,,percent of total billed charges,,,16.23,,,percent of total billed charges,,,,,,,,,16.23,,,fee schedule,,,15.1,,,percent of total billed charges,,,,,,,,,,,,,,,15.1,,,percent of total billed charges,,,15.1,,,percent of total billed charges,,,15.1,,,percent of total billed charges,,,12.17,,,percent of total billed charges,,,16.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.23,,,percent of total billed charges,,,16.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.4,,,percent of total billed charges,,
RISPERIDONE ODT 0.5 MG,2500019236,CDM,637,RC,5974601032,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,16.23,16.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DAPTOMYCIN 500 MG INJ,2500019281,CDM,636,RC,J0878,HCPCS,1671489201,NDC,,,,inpatient,facility,500,GR,214.6,214.6,17.17,214.6,,,,,,,,,,,,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.14,,,percent of total billed charges,,,,,,,,,214.6,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,214.6,,,percent of total billed charges,,,111.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.17,,,percent of total billed charges,,,214.6,,,percent of total billed charges,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.69,,,percent of total billed charges,,
DAPTOMYCIN 500 MG INJ,2500019281,CDM,636,RC,J0878,HCPCS,1671489201,NDC,,,,outpatient,facility,500,GR,214.6,214.6,0.02,618.77,,125.33,,,percent of total billed charges,,,41.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,214.6,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,78.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,193.14,,,percent of total billed charges,,,,,,,,,214.6,,,percent of total billed charges,,,145.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,fee schedule,,,0.04,,,fee schedule,,,,,,,,,618.77,,,per diem,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.89,,,percent of total billed charges,,,214.6,,,percent of total billed charges,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.1,,,percent of total billed charges,,,81.29,,,percent of total billed charges,,,111.14,,,percent of total billed charges,,,,,,,,,,,,,,,42.92,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,214.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,214.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.17,,,percent of total billed charges,,,214.6,,,percent of total billed charges,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,214.6,,,percent of total billed charges,,,214.6,,,percent of total billed charges,,,,,,,,,214.6,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.02,,,fee schedule,,,214.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,214.6,,,percent of total billed charges,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,150.69,,,percent of total billed charges,,
DAPTOMYCIN 500 MG INJ,2500019281,CDM,636,RC,J0878,HCPCS,1671489201,NDC,435,EAPG,,outpatient,facility,500,GR,214.6,214.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEMANTINE HCL 5 MG TAB,2500019286,CDM,637,RC,591387044,NDC,,,,,,inpatient,facility,5,UN,20.13,20.13,1.61,20.13,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.12,,,percent of total billed charges,,,,,,,,,20.13,,,percent of total billed charges,,,11.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,10.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.14,,,percent of total billed charges,,
MEMANTINE HCL 5 MG TAB,2500019286,CDM,637,RC,591387044,NDC,,,,,,outpatient,facility,5,UN,20.13,20.13,1.61,618.77,,11.76,,,percent of total billed charges,,,3.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,20.13,,,percent of total billed charges,,,17.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,17.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,17.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,18.12,,,percent of total billed charges,,,,,,,,,20.13,,,percent of total billed charges,,,13.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.46,,,percent of total billed charges,,,,,,,,,,,,,,,10.87,,,percent of total billed charges,,,10.87,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.5,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.3,,,percent of total billed charges,,,7.63,,,percent of total billed charges,,,10.43,,,percent of total billed charges,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.45,,,percent of total billed charges,,,7.45,,,percent of total billed charges,,,20.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.61,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,20.13,,,fee schedule,,,18.72,,,percent of total billed charges,,,,,,,,,,,,,,,18.72,,,percent of total billed charges,,,18.72,,,percent of total billed charges,,,18.72,,,percent of total billed charges,,,15.1,,,percent of total billed charges,,,20.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,20.13,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,14.14,,,percent of total billed charges,,
MEMANTINE HCL 5 MG TAB,2500019286,CDM,637,RC,591387044,NDC,999,EAPG,,,,outpatient,facility,5,UN,20.13,20.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POLYETHLYENE GLYCOL 17 GM PWD,2500019288,CDM,637,RC,904693181,NDC,,,,,,inpatient,facility,17,UN,2.03,2.03,0.16,2.03,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,2.03,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,
POLYETHLYENE GLYCOL 17 GM PWD,2500019288,CDM,637,RC,904693181,NDC,,,,,,outpatient,facility,17,UN,2.03,2.03,0.16,618.77,,1.19,,,percent of total billed charges,,,0.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.03,,,percent of total billed charges,,,1.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.83,,,percent of total billed charges,,,,,,,,,2.03,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.75,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,2.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,2.03,,,fee schedule,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,2.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.43,,,percent of total billed charges,,
POLYETHLYENE GLYCOL 17 GM PWD,2500019288,CDM,637,RC,904693181,NDC,999,EAPG,,,,outpatient,facility,17,UN,2.03,2.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUTEROL 2.5 MG/0.5 ML,2500019289,CDM,637,RC,487990130,NDC,,,,,,inpatient,facility,0.5,UN,2.97,2.97,0.24,2.97,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.09,,,percent of total billed charges,,
ALBUTEROL 2.5 MG/0.5 ML,2500019289,CDM,637,RC,487990130,NDC,,,,,,outpatient,facility,0.5,UN,2.97,2.97,0.24,618.77,,1.73,,,percent of total billed charges,,,0.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.97,,,percent of total billed charges,,,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.67,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,fee schedule,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.09,,,percent of total billed charges,,
ALBUTEROL 2.5 MG/0.5 ML,2500019289,CDM,637,RC,487990130,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,2.97,2.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIVALPROEX 250MG (DEPAKOTE ER),2500019290,CDM,637,RC,904636345,NDC,,,,,,inpatient,facility,250,UN,5.01,5.01,0.4,5.01,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.51,,,percent of total billed charges,,,,,,,,,5.01,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,5.01,,,percent of total billed charges,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,
DIVALPROEX 250MG (DEPAKOTE ER),2500019290,CDM,637,RC,904636345,NDC,,,,,,outpatient,facility,250,UN,5.01,5.01,0.4,618.77,,2.93,,,percent of total billed charges,,,0.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.01,,,percent of total billed charges,,,4.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.51,,,percent of total billed charges,,,,,,,,,5.01,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,2.71,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,5.01,,,percent of total billed charges,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.81,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,5.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.4,,,percent of total billed charges,,,5.01,,,percent of total billed charges,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,5.01,,,percent of total billed charges,,,,,,,,,5.01,,,fee schedule,,,4.66,,,percent of total billed charges,,,,,,,,,,,,,,,4.66,,,percent of total billed charges,,,4.66,,,percent of total billed charges,,,4.66,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,5.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.01,,,percent of total billed charges,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.52,,,percent of total billed charges,,
DIVALPROEX 250MG (DEPAKOTE ER),2500019290,CDM,637,RC,904636345,NDC,999,EAPG,,,,outpatient,facility,250,UN,5.01,5.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIVALPROEX 500MG (DEPAKOTE ER),2500019291,CDM,637,RC,904636461,NDC,,,,,,inpatient,facility,500,UN,6.79,6.79,0.54,6.79,,,,,,,,,,,,,,6.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.11,,,percent of total billed charges,,,,,,,,,6.79,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.79,,,percent of total billed charges,,,,,,,,,,,,,,,6.79,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,6.79,,,percent of total billed charges,,,6.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,
DIVALPROEX 500MG (DEPAKOTE ER),2500019291,CDM,637,RC,904636461,NDC,,,,,,outpatient,facility,500,UN,6.79,6.79,0.54,618.77,,3.97,,,percent of total billed charges,,,1.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.79,,,percent of total billed charges,,,5.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.11,,,percent of total billed charges,,,,,,,,,6.79,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,3.67,,,percent of total billed charges,,,3.67,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.54,,,percent of total billed charges,,,6.79,,,percent of total billed charges,,,6.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.16,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,6.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.54,,,percent of total billed charges,,,6.79,,,percent of total billed charges,,,6.79,,,percent of total billed charges,,,,,,,,,,,,,,,6.79,,,percent of total billed charges,,,6.79,,,percent of total billed charges,,,,,,,,,6.79,,,fee schedule,,,6.32,,,percent of total billed charges,,,,,,,,,,,,,,,6.32,,,percent of total billed charges,,,6.32,,,percent of total billed charges,,,6.32,,,percent of total billed charges,,,5.09,,,percent of total billed charges,,,6.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.79,,,percent of total billed charges,,,6.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.77,,,percent of total billed charges,,
DIVALPROEX 500MG (DEPAKOTE ER),2500019291,CDM,637,RC,904636461,NDC,999,EAPG,,,,outpatient,facility,500,UN,6.79,6.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CETIRIZINE SOLN 5MG/5 ML UDC,2500019292,CDM,637,RC,6809400462,NDC,,,,,,inpatient,facility,5,UN,9.14,9.14,0.73,9.14,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.23,,,percent of total billed charges,,,,,,,,,9.14,,,percent of total billed charges,,,5.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.42,,,percent of total billed charges,,
CETIRIZINE SOLN 5MG/5 ML UDC,2500019292,CDM,637,RC,6809400462,NDC,,,,,,outpatient,facility,5,UN,9.14,9.14,0.73,618.77,,5.34,,,percent of total billed charges,,,1.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.14,,,percent of total billed charges,,,8.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,8.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,8.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.23,,,percent of total billed charges,,,,,,,,,9.14,,,percent of total billed charges,,,6.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.02,,,percent of total billed charges,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.95,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.38,,,percent of total billed charges,,,3.38,,,percent of total billed charges,,,9.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.73,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,9.14,,,fee schedule,,,8.5,,,percent of total billed charges,,,,,,,,,,,,,,,8.5,,,percent of total billed charges,,,8.5,,,percent of total billed charges,,,8.5,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,9.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.14,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.42,,,percent of total billed charges,,
CETIRIZINE SOLN 5MG/5 ML UDC,2500019292,CDM,637,RC,6809400462,NDC,999,EAPG,,,,outpatient,facility,5,UN,9.14,9.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CL 10MEQ/100 ML IV,2500019297,CDM,636,RC,J3480,HCPCS,338070948,NDC,,,,inpatient,facility,100,ML,13.04,13.04,1.04,13.04,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,,,,,,,13.04,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,
POTASSIUM CL 10MEQ/100 ML IV,2500019297,CDM,636,RC,J3480,HCPCS,338070948,NDC,,,,outpatient,facility,100,ML,13.04,13.04,0.11,618.77,,7.62,,,percent of total billed charges,,,2.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.04,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11.74,,,percent of total billed charges,,,,,,,,,13.04,,,percent of total billed charges,,,8.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.91,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,13.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.04,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,13.04,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,13.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.04,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.16,,,percent of total billed charges,,
POTASSIUM CL 10MEQ/100 ML IV,2500019297,CDM,636,RC,J3480,HCPCS,338070948,NDC,999,EAPG,,outpatient,facility,100,ML,13.04,13.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVONORGESTREL 1.5 MG TAB,2500019303,CDM,637,RC,6818085211,NDC,,,,,,inpatient,facility,1.5,UN,54.84,54.84,4.39,54.84,,,,,,,,,,,,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.36,,,percent of total billed charges,,,,,,,,,54.84,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,54.84,,,percent of total billed charges,,,28.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.39,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.51,,,percent of total billed charges,,
LEVONORGESTREL 1.5 MG TAB,2500019303,CDM,637,RC,6818085211,NDC,,,,,,outpatient,facility,1.5,UN,54.84,54.84,4.39,618.77,,32.03,,,percent of total billed charges,,,10.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,54.84,,,percent of total billed charges,,,48.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,48.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,48.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,20.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,49.36,,,percent of total billed charges,,,,,,,,,54.84,,,percent of total billed charges,,,37.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.12,,,percent of total billed charges,,,,,,,,,,,,,,,29.61,,,percent of total billed charges,,,29.61,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.59,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.68,,,percent of total billed charges,,,20.77,,,percent of total billed charges,,,28.4,,,percent of total billed charges,,,,,,,,,,,,,,,10.97,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,20.29,,,percent of total billed charges,,,20.29,,,percent of total billed charges,,,54.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,54.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.39,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,54.84,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,,,,,,,54.84,,,fee schedule,,,51.01,,,percent of total billed charges,,,,,,,,,,,,,,,51.01,,,percent of total billed charges,,,51.01,,,percent of total billed charges,,,51.01,,,percent of total billed charges,,,41.13,,,percent of total billed charges,,,54.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,54.84,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,38.51,,,percent of total billed charges,,
LEVONORGESTREL 1.5 MG TAB,2500019303,CDM,637,RC,6818085211,NDC,999,EAPG,,,,outpatient,facility,1.5,UN,54.84,54.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATOMOXETINE HCL 40MG CAP,2500019320,CDM,637,RC,6846226830,NDC,,,,,,inpatient,facility,40,UN,51.05,51.05,4.08,51.05,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.95,,,percent of total billed charges,,,,,,,,,51.05,,,percent of total billed charges,,,28.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,26.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.08,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.85,,,percent of total billed charges,,
ATOMOXETINE HCL 40MG CAP,2500019320,CDM,637,RC,6846226830,NDC,,,,,,outpatient,facility,40,UN,51.05,51.05,4.08,618.77,,29.81,,,percent of total billed charges,,,9.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,51.05,,,percent of total billed charges,,,44.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,44.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,44.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,18.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,45.95,,,percent of total billed charges,,,,,,,,,51.05,,,percent of total billed charges,,,34.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.21,,,percent of total billed charges,,,,,,,,,,,,,,,27.57,,,percent of total billed charges,,,27.57,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.62,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.8,,,percent of total billed charges,,,19.34,,,percent of total billed charges,,,26.44,,,percent of total billed charges,,,,,,,,,,,,,,,10.21,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,18.89,,,percent of total billed charges,,,18.89,,,percent of total billed charges,,,51.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.08,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,,,,,,,51.05,,,fee schedule,,,47.49,,,percent of total billed charges,,,,,,,,,,,,,,,47.49,,,percent of total billed charges,,,47.49,,,percent of total billed charges,,,47.49,,,percent of total billed charges,,,38.29,,,percent of total billed charges,,,51.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,51.05,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.85,,,percent of total billed charges,,
ATOMOXETINE HCL 40MG CAP,2500019320,CDM,637,RC,6846226830,NDC,999,EAPG,,,,outpatient,facility,40,UN,51.05,51.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIOTROPIUM BR INHAL 18MC,2500019520,CDM,637,RC,597007541,NDC,,,,,,inpatient,facility,540,UN,56.33,56.33,4.51,56.33,,,,,,,,,,,,,,56.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.7,,,percent of total billed charges,,,,,,,,,56.33,,,percent of total billed charges,,,31.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.33,,,percent of total billed charges,,,,,,,,,,,,,,,56.33,,,percent of total billed charges,,,29.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.51,,,percent of total billed charges,,,56.33,,,percent of total billed charges,,,56.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.55,,,percent of total billed charges,,
TIOTROPIUM BR INHAL 18MC,2500019520,CDM,637,RC,597007541,NDC,,,,,,outpatient,facility,540,UN,56.33,56.33,4.51,618.77,,32.9,,,percent of total billed charges,,,10.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,56.33,,,percent of total billed charges,,,49.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,49.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,49.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,56.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,20.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,50.7,,,percent of total billed charges,,,,,,,,,56.33,,,percent of total billed charges,,,38.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.26,,,percent of total billed charges,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,56.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.37,,,percent of total billed charges,,,56.33,,,percent of total billed charges,,,56.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,percent of total billed charges,,,21.34,,,percent of total billed charges,,,29.17,,,percent of total billed charges,,,,,,,,,,,,,,,11.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,20.84,,,percent of total billed charges,,,20.84,,,percent of total billed charges,,,56.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,56.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.51,,,percent of total billed charges,,,56.33,,,percent of total billed charges,,,56.33,,,percent of total billed charges,,,,,,,,,,,,,,,56.33,,,percent of total billed charges,,,56.33,,,percent of total billed charges,,,,,,,,,56.33,,,fee schedule,,,52.4,,,percent of total billed charges,,,,,,,,,,,,,,,52.4,,,percent of total billed charges,,,52.4,,,percent of total billed charges,,,52.4,,,percent of total billed charges,,,42.25,,,percent of total billed charges,,,56.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,56.33,,,percent of total billed charges,,,56.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,39.55,,,percent of total billed charges,,
TIOTROPIUM BR INHAL 18MC,2500019520,CDM,637,RC,597007541,NDC,999,EAPG,,,,outpatient,facility,540,UN,56.33,56.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPLERENONE 25MG TABLET,2500019540,CDM,637,RC,378103093,NDC,,,,,,inpatient,facility,25,UN,13.76,13.76,1.1,13.76,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.38,,,percent of total billed charges,,,,,,,,,13.76,,,percent of total billed charges,,,7.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,7.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.66,,,percent of total billed charges,,
EPLERENONE 25MG TABLET,2500019540,CDM,637,RC,378103093,NDC,,,,,,outpatient,facility,25,UN,13.76,13.76,1.1,618.77,,8.04,,,percent of total billed charges,,,2.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.76,,,percent of total billed charges,,,12.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.38,,,percent of total billed charges,,,,,,,,,13.76,,,percent of total billed charges,,,9.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.57,,,percent of total billed charges,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.17,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.46,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.09,,,percent of total billed charges,,,5.09,,,percent of total billed charges,,,13.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,13.76,,,fee schedule,,,12.8,,,percent of total billed charges,,,,,,,,,,,,,,,12.8,,,percent of total billed charges,,,12.8,,,percent of total billed charges,,,12.8,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,13.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.76,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.66,,,percent of total billed charges,,
EPLERENONE 25MG TABLET,2500019540,CDM,637,RC,378103093,NDC,999,EAPG,,,,outpatient,facility,25,UN,13.76,13.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IODINE/POTASSIUM IODIDE 8ML,2500019565,CDM,637,RC,1048101118,NDC,,,,,,inpatient,facility,8,UN,16.41,16.41,1.31,16.41,,,,,,,,,,,,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.77,,,percent of total billed charges,,,,,,,,,16.41,,,percent of total billed charges,,,9.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,16.41,,,percent of total billed charges,,,8.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,16.41,,,percent of total billed charges,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.52,,,percent of total billed charges,,
IODINE/POTASSIUM IODIDE 8ML,2500019565,CDM,637,RC,1048101118,NDC,,,,,,outpatient,facility,8,UN,16.41,16.41,1.31,618.77,,9.58,,,percent of total billed charges,,,3.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.41,,,percent of total billed charges,,,14.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,14.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,14.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,6.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,14.77,,,percent of total billed charges,,,,,,,,,16.41,,,percent of total billed charges,,,11.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.6,,,percent of total billed charges,,,,,,,,,,,,,,,8.86,,,percent of total billed charges,,,8.86,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.56,,,percent of total billed charges,,,16.41,,,percent of total billed charges,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,6.22,,,percent of total billed charges,,,8.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.28,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6.07,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,16.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.31,,,percent of total billed charges,,,16.41,,,percent of total billed charges,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,16.41,,,percent of total billed charges,,,16.41,,,percent of total billed charges,,,,,,,,,16.41,,,fee schedule,,,15.26,,,percent of total billed charges,,,,,,,,,,,,,,,15.26,,,percent of total billed charges,,,15.26,,,percent of total billed charges,,,15.26,,,percent of total billed charges,,,12.31,,,percent of total billed charges,,,16.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.41,,,percent of total billed charges,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.52,,,percent of total billed charges,,
IODINE/POTASSIUM IODIDE 8ML,2500019565,CDM,637,RC,1048101118,NDC,999,EAPG,,,,outpatient,facility,8,UN,16.41,16.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RALTEGRAVIR 400 MG TAB,2500019577,CDM,637,RC,6022761,NDC,,,,,,inpatient,facility,400,UN,109.82,109.82,8.79,109.82,,,,,,,,,,,,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.84,,,percent of total billed charges,,,,,,,,,109.82,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,109.82,,,percent of total billed charges,,,57.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.79,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.12,,,percent of total billed charges,,
RALTEGRAVIR 400 MG TAB,2500019577,CDM,637,RC,6022761,NDC,,,,,,outpatient,facility,400,UN,109.82,109.82,8.79,618.77,,64.13,,,percent of total billed charges,,,21.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,109.82,,,percent of total billed charges,,,96.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,96.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,96.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,40.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,98.84,,,percent of total billed charges,,,,,,,,,109.82,,,percent of total billed charges,,,74.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.34,,,percent of total billed charges,,,,,,,,,,,,,,,59.3,,,percent of total billed charges,,,59.3,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.26,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.46,,,percent of total billed charges,,,41.6,,,percent of total billed charges,,,56.88,,,percent of total billed charges,,,,,,,,,,,,,,,21.96,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,40.63,,,percent of total billed charges,,,40.63,,,percent of total billed charges,,,109.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,109.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.79,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,109.82,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,,,,,,,109.82,,,fee schedule,,,102.15,,,percent of total billed charges,,,,,,,,,,,,,,,102.15,,,percent of total billed charges,,,102.15,,,percent of total billed charges,,,102.15,,,percent of total billed charges,,,82.36,,,percent of total billed charges,,,109.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,109.82,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,77.12,,,percent of total billed charges,,
RALTEGRAVIR 400 MG TAB,2500019577,CDM,637,RC,6022761,NDC,999,EAPG,,,,outpatient,facility,400,UN,109.82,109.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIOTROPIUM BR INHLA DEVICE,2500019601,CDM,637,RC,597007575,NDC,,,,,,inpatient,facility,90,UN,66.92,66.92,5.35,66.92,,,,,,,,,,,,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.23,,,percent of total billed charges,,,,,,,,,66.92,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,66.92,,,percent of total billed charges,,,34.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.35,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.99,,,percent of total billed charges,,
TIOTROPIUM BR INHLA DEVICE,2500019601,CDM,637,RC,597007575,NDC,,,,,,outpatient,facility,90,UN,66.92,66.92,5.35,618.77,,39.08,,,percent of total billed charges,,,13.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,66.92,,,percent of total billed charges,,,58.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,58.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,58.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,24.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,60.23,,,percent of total billed charges,,,,,,,,,66.92,,,percent of total billed charges,,,45.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.39,,,percent of total billed charges,,,,,,,,,,,,,,,36.14,,,percent of total billed charges,,,36.14,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.89,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.86,,,percent of total billed charges,,,25.35,,,percent of total billed charges,,,34.66,,,percent of total billed charges,,,,,,,,,,,,,,,13.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,24.76,,,percent of total billed charges,,,24.76,,,percent of total billed charges,,,66.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,66.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.35,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,66.92,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,,,,,,,66.92,,,fee schedule,,,62.25,,,percent of total billed charges,,,,,,,,,,,,,,,62.25,,,percent of total billed charges,,,62.25,,,percent of total billed charges,,,62.25,,,percent of total billed charges,,,50.19,,,percent of total billed charges,,,66.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,66.92,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,46.99,,,percent of total billed charges,,
TIOTROPIUM BR INHLA DEVICE,2500019601,CDM,637,RC,597007575,NDC,999,EAPG,,,,outpatient,facility,90,UN,66.92,66.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOPROLOL SUCC 25 MG TABCR,2500019604,CDM,637,RC,904632261,NDC,,,,,,inpatient,facility,25,UN,2.9,2.9,0.23,2.9,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,2.9,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,
METOPROLOL SUCC 25 MG TABCR,2500019604,CDM,637,RC,904632261,NDC,,,,,,outpatient,facility,25,UN,2.9,2.9,0.23,618.77,,1.69,,,percent of total billed charges,,,0.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.9,,,percent of total billed charges,,,2.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.61,,,percent of total billed charges,,,,,,,,,2.9,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.07,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,2.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,2.9,,,fee schedule,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.04,,,percent of total billed charges,,
METOPROLOL SUCC 25 MG TABCR,2500019604,CDM,637,RC,904632261,NDC,999,EAPG,,,,outpatient,facility,25,UN,2.9,2.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DULOXETINE HCL 30MG ORAL,2500019612,CDM,637,RC,1366811030,NDC,,,,,,inpatient,facility,30,UN,23.15,23.15,1.85,23.15,,,,,,,,,,,,,,23.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.84,,,percent of total billed charges,,,,,,,,,23.15,,,percent of total billed charges,,,12.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.15,,,percent of total billed charges,,,,,,,,,,,,,,,23.15,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,23.15,,,percent of total billed charges,,,23.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.26,,,percent of total billed charges,,
DULOXETINE HCL 30MG ORAL,2500019612,CDM,637,RC,1366811030,NDC,,,,,,outpatient,facility,30,UN,23.15,23.15,1.85,618.77,,13.52,,,percent of total billed charges,,,4.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,23.15,,,percent of total billed charges,,,20.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,20.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,20.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,20.84,,,percent of total billed charges,,,,,,,,,23.15,,,percent of total billed charges,,,15.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.78,,,percent of total billed charges,,,,,,,,,,,,,,,12.5,,,percent of total billed charges,,,12.5,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,23.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,23.15,,,percent of total billed charges,,,23.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.59,,,percent of total billed charges,,,8.77,,,percent of total billed charges,,,11.99,,,percent of total billed charges,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.57,,,percent of total billed charges,,,8.57,,,percent of total billed charges,,,23.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.85,,,percent of total billed charges,,,23.15,,,percent of total billed charges,,,23.15,,,percent of total billed charges,,,,,,,,,,,,,,,23.15,,,percent of total billed charges,,,23.15,,,percent of total billed charges,,,,,,,,,23.15,,,fee schedule,,,21.53,,,percent of total billed charges,,,,,,,,,,,,,,,21.53,,,percent of total billed charges,,,21.53,,,percent of total billed charges,,,21.53,,,percent of total billed charges,,,17.36,,,percent of total billed charges,,,23.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,23.15,,,percent of total billed charges,,,23.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,16.26,,,percent of total billed charges,,
DULOXETINE HCL 30MG ORAL,2500019612,CDM,637,RC,1366811030,NDC,999,EAPG,,,,outpatient,facility,30,UN,23.15,23.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREGABALIN 25 MG CAP,2500019634,CDM,637,RC,6923813109,NDC,,,,,,inpatient,facility,25,UN,27.82,27.82,2.23,27.82,,,,,,,,,,,,,,27.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.04,,,percent of total billed charges,,,,,,,,,27.82,,,percent of total billed charges,,,15.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.82,,,percent of total billed charges,,,,,,,,,,,,,,,27.82,,,percent of total billed charges,,,14.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,27.82,,,percent of total billed charges,,,27.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.54,,,percent of total billed charges,,
PREGABALIN 25 MG CAP,2500019634,CDM,637,RC,6923813109,NDC,,,,,,outpatient,facility,25,UN,27.82,27.82,2.23,618.77,,16.25,,,percent of total billed charges,,,5.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,27.82,,,percent of total billed charges,,,24.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,24.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,24.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,27.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,25.04,,,percent of total billed charges,,,,,,,,,27.82,,,percent of total billed charges,,,18.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.37,,,percent of total billed charges,,,,,,,,,,,,,,,15.02,,,percent of total billed charges,,,15.02,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,27.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.51,,,percent of total billed charges,,,27.82,,,percent of total billed charges,,,27.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.14,,,percent of total billed charges,,,10.54,,,percent of total billed charges,,,14.41,,,percent of total billed charges,,,,,,,,,,,,,,,5.56,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.29,,,percent of total billed charges,,,10.29,,,percent of total billed charges,,,27.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.23,,,percent of total billed charges,,,27.82,,,percent of total billed charges,,,27.82,,,percent of total billed charges,,,,,,,,,,,,,,,27.82,,,percent of total billed charges,,,27.82,,,percent of total billed charges,,,,,,,,,27.82,,,fee schedule,,,25.88,,,percent of total billed charges,,,,,,,,,,,,,,,25.88,,,percent of total billed charges,,,25.88,,,percent of total billed charges,,,25.88,,,percent of total billed charges,,,20.87,,,percent of total billed charges,,,27.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,27.82,,,percent of total billed charges,,,27.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,19.54,,,percent of total billed charges,,
PREGABALIN 25 MG CAP,2500019634,CDM,637,RC,6923813109,NDC,999,EAPG,,,,outpatient,facility,25,UN,27.82,27.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREGABALIN 50 MG CAP,2500019635,CDM,637,RC,904699261,NDC,,,,,,inpatient,facility,50,UN,2.47,2.47,0.2,2.47,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,,,,,,,,2.47,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,
PREGABALIN 50 MG CAP,2500019635,CDM,637,RC,904699261,NDC,,,,,,outpatient,facility,50,UN,2.47,2.47,0.2,618.77,,1.44,,,percent of total billed charges,,,0.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.47,,,percent of total billed charges,,,2.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.22,,,percent of total billed charges,,,,,,,,,2.47,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.91,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,2.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,,,,,,,2.47,,,fee schedule,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,2.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.47,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.73,,,percent of total billed charges,,
PREGABALIN 50 MG CAP,2500019635,CDM,637,RC,904699261,NDC,999,EAPG,,,,outpatient,facility,50,UN,2.47,2.47,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREGABALIN 75 MG CAP,2500019636,CDM,637,RC,904700061,NDC,,,,,,inpatient,facility,75,UN,2.54,2.54,0.2,2.54,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.29,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,
PREGABALIN 75 MG CAP,2500019636,CDM,637,RC,904700061,NDC,,,,,,outpatient,facility,75,UN,2.54,2.54,0.2,618.77,,1.48,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.54,,,percent of total billed charges,,,2.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.29,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.94,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,2.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,2.54,,,fee schedule,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,2.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.78,,,percent of total billed charges,,
PREGABALIN 75 MG CAP,2500019636,CDM,637,RC,904700061,NDC,999,EAPG,,,,outpatient,facility,75,UN,2.54,2.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACAMPROSATE 333MG TABDR,2500019641,CDM,637,RC,6846243518,NDC,,,,,,inpatient,facility,333,UN,5.81,5.81,0.46,5.81,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.23,,,percent of total billed charges,,,,,,,,,5.81,,,percent of total billed charges,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.08,,,percent of total billed charges,,
ACAMPROSATE 333MG TABDR,2500019641,CDM,637,RC,6846243518,NDC,,,,,,outpatient,facility,333,UN,5.81,5.81,0.46,618.77,,3.39,,,percent of total billed charges,,,1.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.81,,,percent of total billed charges,,,5.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.23,,,percent of total billed charges,,,,,,,,,5.81,,,percent of total billed charges,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,2.2,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,5.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,5.81,,,fee schedule,,,5.4,,,percent of total billed charges,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,4.36,,,percent of total billed charges,,,5.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.81,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.08,,,percent of total billed charges,,
ACAMPROSATE 333MG TABDR,2500019641,CDM,637,RC,6846243518,NDC,999,EAPG,,,,outpatient,facility,333,UN,5.81,5.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DULOXETINE HCL 20MG ORAL,2500019643,CDM,637,RC,7161040183,NDC,,,,,,inpatient,facility,20,UN,0.92,0.92,0.07,0.92,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,
DULOXETINE HCL 20MG ORAL,2500019643,CDM,637,RC,7161040183,NDC,,,,,,outpatient,facility,20,UN,0.92,0.92,0.07,618.77,,0.54,,,percent of total billed charges,,,0.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,0.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.83,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.34,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,0.92,,,fee schedule,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.65,,,percent of total billed charges,,
DULOXETINE HCL 20MG ORAL,2500019643,CDM,637,RC,7161040183,NDC,999,EAPG,,,,outpatient,facility,20,UN,0.92,0.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BETAMETH AC NA PHOS 6 MG INJ,2500019651,CDM,636,RC,J0702,HCPCS,517072001,NDC,,,,inpatient,facility,1,ML,36.33,36.33,2.91,36.33,,,,,,,,,,,,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,,,,,,,36.33,,,percent of total billed charges,,,20.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,36.33,,,percent of total billed charges,,,18.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,36.33,,,percent of total billed charges,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,,percent of total billed charges,,
BETAMETH AC NA PHOS 6 MG INJ,2500019651,CDM,636,RC,J0702,HCPCS,517072001,NDC,,,,outpatient,facility,1,ML,36.33,36.33,2.91,618.77,,21.22,,,percent of total billed charges,,,7.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,36.33,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,13.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,32.7,,,percent of total billed charges,,,,,,,,,36.33,,,percent of total billed charges,,,24.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.94,,,percent of total billed charges,,,36.33,,,percent of total billed charges,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.61,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,18.82,,,percent of total billed charges,,,,,,,,,,,,,,,7.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,36.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,36.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.91,,,percent of total billed charges,,,36.33,,,percent of total billed charges,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,36.33,,,percent of total billed charges,,,36.33,,,percent of total billed charges,,,,,,,,,36.33,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,7.55,,,fee schedule,,,36.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,36.33,,,percent of total billed charges,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,25.51,,,percent of total billed charges,,
BETAMETH AC NA PHOS 6 MG INJ,2500019651,CDM,636,RC,J0702,HCPCS,517072001,NDC,496,EAPG,,outpatient,facility,1,ML,36.33,36.33,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFAZOLIN SOD 2 GM INJ,2500019654,CDM,636,RC,J0690,HCPCS,,,,,,inpatient,facility,20,GR,24.12,24.12,1.93,24.12,,,,,,,,,,,,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.71,,,percent of total billed charges,,,,,,,,,24.12,,,percent of total billed charges,,,13.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,24.12,,,percent of total billed charges,,,12.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.94,,,percent of total billed charges,,
CEFAZOLIN SOD 2 GM INJ,2500019654,CDM,636,RC,J0690,HCPCS,,,,,,outpatient,facility,20,GR,24.12,24.12,0.85,618.77,,14.09,,,percent of total billed charges,,,4.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,24.12,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,21.71,,,percent of total billed charges,,,,,,,,,24.12,,,percent of total billed charges,,,16.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.58,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.33,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,4.82,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,24.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.93,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,24.12,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,,,,,,,24.12,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,24.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,24.12,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,16.94,,,percent of total billed charges,,
CEFAZOLIN SOD 2 GM INJ,2500019654,CDM,636,RC,J0690,HCPCS,496,EAPG,,,,outpatient,facility,20,GR,24.12,24.12,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOPROSTENOL INJ 1.5 MG,2500019656,CDM,636,RC,J1325,HCPCS,6621540201,NDC,,,,inpatient,facility,50,UN,172.03,172.03,13.76,172.03,,,,,,,,,,,,,,172.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.83,,,percent of total billed charges,,,,,,,,,172.03,,,percent of total billed charges,,,95.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.03,,,percent of total billed charges,,,,,,,,,,,,,,,172.03,,,percent of total billed charges,,,89.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,172.03,,,percent of total billed charges,,,172.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,172.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.8,,,percent of total billed charges,,
EPOPROSTENOL INJ 1.5 MG,2500019656,CDM,636,RC,J1325,HCPCS,6621540201,NDC,,,,outpatient,facility,50,UN,172.03,172.03,13.76,618.77,,100.47,,,percent of total billed charges,,,33.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,172.03,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,172.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,62.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,154.83,,,percent of total billed charges,,,,,,,,,172.03,,,percent of total billed charges,,,116.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,172.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89.7,,,percent of total billed charges,,,172.03,,,percent of total billed charges,,,172.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.74,,,percent of total billed charges,,,65.16,,,percent of total billed charges,,,89.09,,,percent of total billed charges,,,,,,,,,,,,,,,34.41,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,172.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,172.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.76,,,percent of total billed charges,,,172.03,,,percent of total billed charges,,,172.03,,,percent of total billed charges,,,,,,,,,,,,,,,172.03,,,percent of total billed charges,,,172.03,,,percent of total billed charges,,,,,,,,,172.03,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,17.09,,,fee schedule,,,172.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,172.03,,,percent of total billed charges,,,172.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,120.8,,,percent of total billed charges,,
EPOPROSTENOL INJ 1.5 MG,2500019656,CDM,636,RC,J1325,HCPCS,6621540201,NDC,999,EAPG,,outpatient,facility,50,UN,172.03,172.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL 12 MCG TDSY,2500019657,CDM,637,RC,6050570802,NDC,,,,,,inpatient,facility,1,UN,66.99,66.99,5.36,66.99,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.29,,,percent of total billed charges,,,,,,,,,66.99,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,34.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.36,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.04,,,percent of total billed charges,,
FENTANYL 12 MCG TDSY,2500019657,CDM,637,RC,6050570802,NDC,,,,,,outpatient,facility,1,UN,66.99,66.99,5.36,618.77,,39.12,,,percent of total billed charges,,,13.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,66.99,,,percent of total billed charges,,,58.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,58.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,58.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,24.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,60.29,,,percent of total billed charges,,,,,,,,,66.99,,,percent of total billed charges,,,45.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.45,,,percent of total billed charges,,,,,,,,,,,,,,,36.17,,,percent of total billed charges,,,36.17,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.93,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.91,,,percent of total billed charges,,,25.38,,,percent of total billed charges,,,34.69,,,percent of total billed charges,,,,,,,,,,,,,,,13.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,24.79,,,percent of total billed charges,,,24.79,,,percent of total billed charges,,,66.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,66.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.36,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,,,,,,,66.99,,,fee schedule,,,62.31,,,percent of total billed charges,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,62.31,,,percent of total billed charges,,,62.31,,,percent of total billed charges,,,50.24,,,percent of total billed charges,,,66.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,47.04,,,percent of total billed charges,,
FENTANYL 12 MCG TDSY,2500019657,CDM,637,RC,6050570802,NDC,999,EAPG,,,,outpatient,facility,1,UN,66.99,66.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL 2MCG/BUP 0.125 100ML,2500019659,CDM,636,RC,J3010,HCPCS,,,,,,inpatient,facility,100,UN,25.21,25.21,2.02,25.21,,,,,,,,,,,,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.69,,,percent of total billed charges,,,,,,,,,25.21,,,percent of total billed charges,,,13.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,25.21,,,percent of total billed charges,,,13.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,25.21,,,percent of total billed charges,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.7,,,percent of total billed charges,,
FENTANYL 2MCG/BUP 0.125 100ML,2500019659,CDM,636,RC,J3010,HCPCS,,,,,,outpatient,facility,100,UN,25.21,25.21,0.87,618.77,,14.72,,,percent of total billed charges,,,4.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,25.21,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22.69,,,percent of total billed charges,,,,,,,,,25.21,,,percent of total billed charges,,,17.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.14,,,percent of total billed charges,,,25.21,,,percent of total billed charges,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.16,,,percent of total billed charges,,,9.55,,,percent of total billed charges,,,13.06,,,percent of total billed charges,,,,,,,,,,,,,,,5.04,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,25.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.02,,,percent of total billed charges,,,25.21,,,percent of total billed charges,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,25.21,,,percent of total billed charges,,,25.21,,,percent of total billed charges,,,,,,,,,25.21,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.87,,,fee schedule,,,25.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,25.21,,,percent of total billed charges,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.7,,,percent of total billed charges,,
FENTANYL 2MCG/BUP 0.125 100ML,2500019659,CDM,636,RC,J3010,HCPCS,496,EAPG,,,,outpatient,facility,100,UN,25.21,25.21,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAMINOPHEN 160 MG/5 ML UDC,2500019704,CDM,637,RC,121065700,NDC,,,,,,inpatient,facility,5,UN,2.91,2.91,0.23,2.91,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,,,,,,,2.91,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,
ACETAMINOPHEN 160 MG/5 ML UDC,2500019704,CDM,637,RC,121065700,NDC,,,,,,outpatient,facility,5,UN,2.91,2.91,0.23,618.77,,1.7,,,percent of total billed charges,,,0.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.91,,,percent of total billed charges,,,2.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.62,,,percent of total billed charges,,,,,,,,,2.91,,,percent of total billed charges,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,2.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,2.91,,,fee schedule,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,2.71,,,percent of total billed charges,,,2.71,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.91,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.04,,,percent of total billed charges,,
ACETAMINOPHEN 160 MG/5 ML UDC,2500019704,CDM,637,RC,121065700,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.91,2.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMANTADINE 100 MG/10 ML UDC,2500019718,CDM,637,RC,121064610,NDC,,,,,,inpatient,facility,10,UN,14.22,14.22,1.14,14.22,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.8,,,percent of total billed charges,,,,,,,,,14.22,,,percent of total billed charges,,,7.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,7.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.99,,,percent of total billed charges,,
AMANTADINE 100 MG/10 ML UDC,2500019718,CDM,637,RC,121064610,NDC,,,,,,outpatient,facility,10,UN,14.22,14.22,1.14,618.77,,8.3,,,percent of total billed charges,,,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.22,,,percent of total billed charges,,,12.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.8,,,percent of total billed charges,,,,,,,,,14.22,,,percent of total billed charges,,,9.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,7.68,,,percent of total billed charges,,,7.68,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.41,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.81,,,percent of total billed charges,,,5.39,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.26,,,percent of total billed charges,,,5.26,,,percent of total billed charges,,,14.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.14,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,,,,,,,14.22,,,fee schedule,,,13.23,,,percent of total billed charges,,,,,,,,,,,,,,,13.23,,,percent of total billed charges,,,13.23,,,percent of total billed charges,,,13.23,,,percent of total billed charges,,,10.67,,,percent of total billed charges,,,14.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.22,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.11,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.99,,,percent of total billed charges,,
AMANTADINE 100 MG/10 ML UDC,2500019718,CDM,637,RC,121064610,NDC,999,EAPG,,,,outpatient,facility,10,UN,14.22,14.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATOVAQ/PROGUAN 250MG/100MG TAB,2500019736,CDM,637,RC,6699306027,NDC,,,,,,inpatient,facility,1,UN,24.45,24.45,1.96,24.45,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22,,,percent of total billed charges,,,,,,,,,24.45,,,percent of total billed charges,,,13.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.17,,,percent of total billed charges,,
ATOVAQ/PROGUAN 250MG/100MG TAB,2500019736,CDM,637,RC,6699306027,NDC,,,,,,outpatient,facility,1,UN,24.45,24.45,1.96,618.77,,14.28,,,percent of total billed charges,,,4.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,24.45,,,percent of total billed charges,,,21.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,21.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,21.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22,,,percent of total billed charges,,,,,,,,,24.45,,,percent of total billed charges,,,16.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.78,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.75,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.58,,,percent of total billed charges,,,9.26,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,9.05,,,percent of total billed charges,,,9.05,,,percent of total billed charges,,,24.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.96,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,24.45,,,fee schedule,,,22.74,,,percent of total billed charges,,,,,,,,,,,,,,,22.74,,,percent of total billed charges,,,22.74,,,percent of total billed charges,,,22.74,,,percent of total billed charges,,,18.34,,,percent of total billed charges,,,24.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.17,,,percent of total billed charges,,
ATOVAQ/PROGUAN 250MG/100MG TAB,2500019736,CDM,637,RC,6699306027,NDC,999,EAPG,,,,outpatient,facility,1,UN,24.45,24.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BALSALAZIDE 750 MG CAP,2500019738,CDM,637,RC,6050525757,NDC,,,,,,inpatient,facility,750,UN,5.28,5.28,0.42,5.28,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,5.28,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.71,,,percent of total billed charges,,
BALSALAZIDE 750 MG CAP,2500019738,CDM,637,RC,6050525757,NDC,,,,,,outpatient,facility,750,UN,5.28,5.28,0.42,618.77,,3.08,,,percent of total billed charges,,,1.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.28,,,percent of total billed charges,,,4.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.75,,,percent of total billed charges,,,,,,,,,5.28,,,percent of total billed charges,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,5.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.42,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,5.28,,,fee schedule,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,5.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.71,,,percent of total billed charges,,
BALSALAZIDE 750 MG CAP,2500019738,CDM,637,RC,6050525757,NDC,999,EAPG,,,,outpatient,facility,750,UN,5.28,5.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZOCAINE 7 GM TUBE,2500019744,CDM,637,RC,1191707171,NDC,,,,,,inpatient,facility,7,UN,6.99,6.99,0.56,6.99,,,,,,,,,,,,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.29,,,percent of total billed charges,,,,,,,,,6.99,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,6.99,,,percent of total billed charges,,,3.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,
BENZOCAINE 7 GM TUBE,2500019744,CDM,637,RC,1191707171,NDC,,,,,,outpatient,facility,7,UN,6.99,6.99,0.56,618.77,,4.08,,,percent of total billed charges,,,1.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.99,,,percent of total billed charges,,,6.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.29,,,percent of total billed charges,,,,,,,,,6.99,,,percent of total billed charges,,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.37,,,percent of total billed charges,,,,,,,,,,,,,,,3.77,,,percent of total billed charges,,,3.77,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,3.62,,,percent of total billed charges,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.59,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,6.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,6.99,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,,,,,,,6.99,,,fee schedule,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,5.24,,,percent of total billed charges,,,6.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.99,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.91,,,percent of total billed charges,,
BENZOCAINE 7 GM TUBE,2500019744,CDM,637,RC,1191707171,NDC,999,EAPG,,,,outpatient,facility,7,UN,6.99,6.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BETA-CAROTENE W/C   MINERALS,2500019747,CDM,637,RC,536509008,NDC,,,,,,inpatient,facility,1,UN,0.2,0.2,0.02,0.2,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,0.2,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,
BETA-CAROTENE W/C   MINERALS,2500019747,CDM,637,RC,536509008,NDC,,,,,,outpatient,facility,1,UN,0.2,0.2,0.02,618.77,,0.12,,,percent of total billed charges,,,0.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,0.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.18,,,percent of total billed charges,,,,,,,,,0.2,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,0.08,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.07,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,0.2,,,fee schedule,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,0.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.14,,,percent of total billed charges,,
BETA-CAROTENE W/C   MINERALS,2500019747,CDM,637,RC,536509008,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.2,0.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUDESONIDE 0.25 MG/2ML NEB SOL,2500019754,CDM,637,RC,J7626,HCPCS,93681555,NDC,,,,inpatient,facility,2,UN,31.05,31.05,2.48,31.05,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.95,,,percent of total billed charges,,,,,,,,,31.05,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,16.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.8,,,percent of total billed charges,,
BUDESONIDE 0.25 MG/2ML NEB SOL,2500019754,CDM,637,RC,J7626,HCPCS,93681555,NDC,,,,outpatient,facility,2,UN,31.05,31.05,0.66,618.77,,18.13,,,percent of total billed charges,,,6.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,31.05,,,percent of total billed charges,,,1.41,,,fee schedule,,,1.36,,,fee schedule,,,,,,,,,1.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,27.95,,,percent of total billed charges,,,,,,,,,31.05,,,percent of total billed charges,,,21.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,fee schedule,,,1.01,,,fee schedule,,,,,,,,,618.77,,,per diem,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.19,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.6,,,percent of total billed charges,,,11.76,,,percent of total billed charges,,,16.08,,,percent of total billed charges,,,,,,,,,,,,,,,6.21,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.12,,,fee schedule,,,0.94,,,fee schedule,,,31.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.48,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,,,,,,,1.23,,,fee schedule,,,1.01,,,fee schedule,,,,,,,,,,,,,,,0.89,,,fee schedule,,,1.18,,,fee schedule,,,0.66,,,fee schedule,,,1.23,,,fee schedule,,,31.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,31.05,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,21.8,,,percent of total billed charges,,
BUDESONIDE 0.25 MG/2ML NEB SOL,2500019754,CDM,637,RC,J7626,HCPCS,93681555,NDC,496,EAPG,,outpatient,facility,2,UN,31.05,31.05,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE/EPI 0.2510 ML INJ,2500019765,CDM,250,RC,J3490,HCPCS,6332346817,NDC,,,,inpatient,facility,10,UN,22.14,22.14,1.77,22.14,,,,,,,,,,,,,,22.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.93,,,percent of total billed charges,,,,,,,,,22.14,,,percent of total billed charges,,,12.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.14,,,percent of total billed charges,,,,,,,,,,,,,,,22.14,,,percent of total billed charges,,,11.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.55,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.2510 ML INJ,2500019765,CDM,250,RC,J3490,HCPCS,6332346817,NDC,,,,outpatient,facility,10,UN,22.14,22.14,1.2,618.77,,12.93,,,percent of total billed charges,,,4.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,22.14,,,percent of total billed charges,,,19.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,19.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,19.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,22.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,8.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,19.93,,,percent of total billed charges,,,,,,,,,22.14,,,percent of total billed charges,,,14.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17,,,percent of total billed charges,,,,,,,,,,,,,,,22.14,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,22.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.54,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.83,,,percent of total billed charges,,,8.39,,,percent of total billed charges,,,11.47,,,percent of total billed charges,,,,,,,,,,,,,,,4.43,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,22.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.77,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,,,,,,,,,,,,,22.14,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,,,,,,,22.14,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,16.61,,,percent of total billed charges,,,22.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,22.14,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,15.55,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.2510 ML INJ,2500019765,CDM,250,RC,J3490,HCPCS,6332346817,NDC,435,EAPG,,outpatient,facility,10,UN,22.14,22.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORPROMAZINE 25 MG/ML INJ,2500019806,CDM,636,RC,J3230,HCPCS,641139735,NDC,,,,inpatient,facility,1,UN,95.34,95.34,7.63,95.34,,,,,,,,,,,,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.81,,,percent of total billed charges,,,,,,,,,95.34,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,95.34,,,percent of total billed charges,,,49.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.63,,,percent of total billed charges,,,95.34,,,percent of total billed charges,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.95,,,percent of total billed charges,,
CHLORPROMAZINE 25 MG/ML INJ,2500019806,CDM,636,RC,J3230,HCPCS,641139735,NDC,,,,outpatient,facility,1,UN,95.34,95.34,7.63,618.77,,55.68,,,percent of total billed charges,,,18.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,95.34,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,34.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,85.81,,,percent of total billed charges,,,,,,,,,95.34,,,percent of total billed charges,,,64.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.71,,,percent of total billed charges,,,95.34,,,percent of total billed charges,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.46,,,percent of total billed charges,,,36.11,,,percent of total billed charges,,,49.38,,,percent of total billed charges,,,,,,,,,,,,,,,19.07,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,95.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,95.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.63,,,percent of total billed charges,,,95.34,,,percent of total billed charges,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,95.34,,,percent of total billed charges,,,95.34,,,percent of total billed charges,,,,,,,,,95.34,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,31.23,,,fee schedule,,,95.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,95.34,,,percent of total billed charges,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.67,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,66.95,,,percent of total billed charges,,
CHLORPROMAZINE 25 MG/ML INJ,2500019806,CDM,636,RC,J3230,HCPCS,641139735,NDC,435,EAPG,,outpatient,facility,1,UN,95.34,95.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROSUVASTATIN 10 MG TAB,2500019823,CDM,637,RC,6846226290,NDC,,,,,,inpatient,facility,10,UN,29.5,29.5,2.36,29.5,,,,,,,,,,,,,,29.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.55,,,percent of total billed charges,,,,,,,,,29.5,,,percent of total billed charges,,,16.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.5,,,percent of total billed charges,,,,,,,,,,,,,,,29.5,,,percent of total billed charges,,,15.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,29.5,,,percent of total billed charges,,,29.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.71,,,percent of total billed charges,,
ROSUVASTATIN 10 MG TAB,2500019823,CDM,637,RC,6846226290,NDC,,,,,,outpatient,facility,10,UN,29.5,29.5,2.36,618.77,,17.23,,,percent of total billed charges,,,5.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,29.5,,,percent of total billed charges,,,25.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,25.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,25.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26.55,,,percent of total billed charges,,,,,,,,,29.5,,,percent of total billed charges,,,19.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.66,,,percent of total billed charges,,,,,,,,,,,,,,,15.93,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,29.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.38,,,percent of total billed charges,,,29.5,,,percent of total billed charges,,,29.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.42,,,percent of total billed charges,,,11.17,,,percent of total billed charges,,,15.28,,,percent of total billed charges,,,,,,,,,,,,,,,5.9,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.91,,,percent of total billed charges,,,10.91,,,percent of total billed charges,,,29.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.36,,,percent of total billed charges,,,29.5,,,percent of total billed charges,,,29.5,,,percent of total billed charges,,,,,,,,,,,,,,,29.5,,,percent of total billed charges,,,29.5,,,percent of total billed charges,,,,,,,,,29.5,,,fee schedule,,,27.44,,,percent of total billed charges,,,,,,,,,,,,,,,27.44,,,percent of total billed charges,,,27.44,,,percent of total billed charges,,,27.44,,,percent of total billed charges,,,22.13,,,percent of total billed charges,,,29.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,29.5,,,percent of total billed charges,,,29.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.71,,,percent of total billed charges,,
ROSUVASTATIN 10 MG TAB,2500019823,CDM,637,RC,6846226290,NDC,999,EAPG,,,,outpatient,facility,10,UN,29.5,29.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSULIN LISPRO 1 UNIT INJ,2500019827,CDM,637,RC,J1815,HCPCS,2751001,NDC,,,,inpatient,facility,0.01,UN,0.29,0.29,0.02,0.29,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,
INSULIN LISPRO 1 UNIT INJ,2500019827,CDM,637,RC,J1815,HCPCS,2751001,NDC,,,,outpatient,facility,0.01,UN,0.29,0.29,0.02,618.77,,0.17,,,percent of total billed charges,,,0.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.29,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.26,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.29,,,fee schedule,,,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.2,,,percent of total billed charges,,
INSULIN LISPRO 1 UNIT INJ,2500019827,CDM,637,RC,J1815,HCPCS,2751001,NDC,496,EAPG,,outpatient,facility,0.01,UN,0.29,0.29,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSULIN LISPRO MIX 75/25 1UNIT,2500019828,CDM,637,RC,J1815,HCPCS,2751101,NDC,,,,inpatient,facility,0.01,UN,1.12,1.12,0.09,1.12,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,1.12,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,
INSULIN LISPRO MIX 75/25 1UNIT,2500019828,CDM,637,RC,J1815,HCPCS,2751101,NDC,,,,outpatient,facility,0.01,UN,1.12,1.12,0.09,618.77,,0.65,,,percent of total billed charges,,,0.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.12,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.01,,,percent of total billed charges,,,,,,,,,1.12,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,1.12,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.94,,,fee schedule,,,1.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.79,,,percent of total billed charges,,
INSULIN LISPRO MIX 75/25 1UNIT,2500019828,CDM,637,RC,J1815,HCPCS,2751101,NDC,496,EAPG,,outpatient,facility,0.01,UN,1.12,1.12,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CINACALCET 30 MG TAB,2500019830,CDM,637,RC,J0604,HCPCS,7043600704,NDC,,,,inpatient,facility,30,UN,102.03,102.03,8.16,102.03,,,,,,,,,,,,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.83,,,percent of total billed charges,,,,,,,,,102.03,,,percent of total billed charges,,,56.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,102.03,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.16,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.65,,,percent of total billed charges,,
CINACALCET 30 MG TAB,2500019830,CDM,637,RC,J0604,HCPCS,7043600704,NDC,,,,outpatient,facility,30,UN,102.03,102.03,0.02,618.77,,59.59,,,percent of total billed charges,,,19.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,102.03,,,percent of total billed charges,,,0.02,,,fee schedule,,,0.02,,,fee schedule,,,,,,,,,0.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,37.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,91.83,,,percent of total billed charges,,,,,,,,,102.03,,,percent of total billed charges,,,69.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,fee schedule,,,0.03,,,fee schedule,,,,,,,,,618.77,,,per diem,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.2,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.54,,,percent of total billed charges,,,38.65,,,percent of total billed charges,,,52.84,,,percent of total billed charges,,,,,,,,,,,,,,,20.41,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.81,,,fee schedule,,,0.81,,,fee schedule,,,102.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,102.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.16,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,102.03,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,,,,,,,102.03,,,fee schedule,,,0.86,,,fee schedule,,,,,,,,,,,,,,,0.76,,,fee schedule,,,1.01,,,fee schedule,,,0.56,,,fee schedule,,,76.52,,,percent of total billed charges,,,102.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,102.03,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,71.65,,,percent of total billed charges,,
CINACALCET 30 MG TAB,2500019830,CDM,637,RC,J0604,HCPCS,7043600704,NDC,436,EAPG,,outpatient,facility,30,UN,102.03,102.03,126.95,186.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.11,,,fee schedule,,,126.95,,,fee schedule,,,165.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VARENICLINE 0.5 MG (CHANTIX),2500019855,CDM,637,RC,4988415576,NDC,,,,,,inpatient,facility,0.5,UN,29,29,2.32,29,,,,,,,,,,,,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.1,,,percent of total billed charges,,,,,,,,,29,,,percent of total billed charges,,,16.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,29,,,percent of total billed charges,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.36,,,percent of total billed charges,,
VARENICLINE 0.5 MG (CHANTIX),2500019855,CDM,637,RC,4988415576,NDC,,,,,,outpatient,facility,0.5,UN,29,29,2.32,618.77,,16.94,,,percent of total billed charges,,,5.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,29,,,percent of total billed charges,,,25.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,25.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,25.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26.1,,,percent of total billed charges,,,,,,,,,29,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.27,,,percent of total billed charges,,,,,,,,,,,,,,,15.66,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.12,,,percent of total billed charges,,,29,,,percent of total billed charges,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.04,,,percent of total billed charges,,,10.99,,,percent of total billed charges,,,15.02,,,percent of total billed charges,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.73,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.32,,,percent of total billed charges,,,29,,,percent of total billed charges,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,29,,,percent of total billed charges,,,,,,,,,29,,,fee schedule,,,26.98,,,percent of total billed charges,,,,,,,,,,,,,,,26.98,,,percent of total billed charges,,,26.98,,,percent of total billed charges,,,26.98,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,29,,,percent of total billed charges,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.36,,,percent of total billed charges,,
VARENICLINE 0.5 MG (CHANTIX),2500019855,CDM,637,RC,4988415576,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,29,29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MELATONIN 3 MG TAB,2500019882,CDM,637,RC,2055503601,NDC,,,,,,inpatient,facility,3,UN,0.5,0.5,0.04,0.5,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,
MELATONIN 3 MG TAB,2500019882,CDM,637,RC,2055503601,NDC,,,,,,outpatient,facility,3,UN,0.5,0.5,0.04,618.77,,0.29,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.5,,,percent of total billed charges,,,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.45,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.18,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,0.5,,,fee schedule,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,0.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.35,,,percent of total billed charges,,
MELATONIN 3 MG TAB,2500019882,CDM,637,RC,2055503601,NDC,999,EAPG,,,,outpatient,facility,3,UN,0.5,0.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PALIPERIDONE 3 MG TAB,2500019900,CDM,637,RC,6516228103,NDC,,,,,,inpatient,facility,3,UN,100.98,100.98,8.08,100.98,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.88,,,percent of total billed charges,,,,,,,,,100.98,,,percent of total billed charges,,,55.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,52.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.08,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.91,,,percent of total billed charges,,
PALIPERIDONE 3 MG TAB,2500019900,CDM,637,RC,6516228103,NDC,,,,,,outpatient,facility,3,UN,100.98,100.98,8.08,618.77,,58.97,,,percent of total billed charges,,,19.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,100.98,,,percent of total billed charges,,,88.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,88.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,88.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,36.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,90.88,,,percent of total billed charges,,,,,,,,,100.98,,,percent of total billed charges,,,68.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.55,,,percent of total billed charges,,,,,,,,,,,,,,,54.53,,,percent of total billed charges,,,54.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.65,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.74,,,percent of total billed charges,,,38.25,,,percent of total billed charges,,,52.3,,,percent of total billed charges,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,37.36,,,percent of total billed charges,,,37.36,,,percent of total billed charges,,,100.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,100.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.08,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,100.98,,,fee schedule,,,93.93,,,percent of total billed charges,,,,,,,,,,,,,,,93.93,,,percent of total billed charges,,,93.93,,,percent of total billed charges,,,93.93,,,percent of total billed charges,,,75.73,,,percent of total billed charges,,,100.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,100.98,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,70.91,,,percent of total billed charges,,
PALIPERIDONE 3 MG TAB,2500019900,CDM,637,RC,6516228103,NDC,999,EAPG,,,,outpatient,facility,3,UN,100.98,100.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PALIPERIDONE 234 MG IM,2500019908,CDM,636,RC,J2426,HCPCS,5045856401,NDC,,,,inpatient,facility,1.5,UN,11479.71,11479.71,918.38,11479.71,,,,,,,,,,,,,,11479.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10331.74,,,percent of total billed charges,,,,,,,,,11479.71,,,percent of total billed charges,,,6355.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10474.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11479.71,,,percent of total billed charges,,,,,,,,,,,,,,,11479.71,,,percent of total billed charges,,,5985.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2295.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,918.38,,,percent of total billed charges,,,11479.71,,,percent of total billed charges,,,11479.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11479.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8061.05,,,percent of total billed charges,,
PALIPERIDONE 234 MG IM,2500019908,CDM,636,RC,J2426,HCPCS,5045856401,NDC,,,,outpatient,facility,1.5,UN,11479.71,11479.71,9.06,11479.71,,6704.15,,,percent of total billed charges,,,,,,,,,11479.71,,,percent of total billed charges,,,17.33,,,fee schedule,,,16.7,,,fee schedule,,,,,,,,,16.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,11479.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10331.74,,,percent of total billed charges,,,,,,,,,11479.71,,,percent of total billed charges,,,7774.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8816.42,,,percent of total billed charges,,,,,,,,,,,,,,,14.32,,,fee schedule,,,14.32,,,fee schedule,,,,,,,,,618.77,,,per diem,,,11479.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5985.52,,,percent of total billed charges,,,11479.71,,,percent of total billed charges,,,11479.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8724.58,,,percent of total billed charges,,,4348.51,,,percent of total billed charges,,,5945.34,,,percent of total billed charges,,,,,,,,,,,,,,,2295.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,29.31,,,fee schedule,,,13.07,,,fee schedule,,,,,,,,,,,,,,,918.38,,,percent of total billed charges,,,11479.71,,,percent of total billed charges,,,11479.71,,,percent of total billed charges,,,,,,,,,,,,,,,11479.71,,,percent of total billed charges,,,11479.71,,,percent of total billed charges,,,,,,,,,11479.71,,,fee schedule,,,13.94,,,fee schedule,,,,,,,,,,,,,,,12.26,,,fee schedule,,,16.35,,,fee schedule,,,9.06,,,fee schedule,,,15.21,,,fee schedule,,,11479.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11479.71,,,percent of total billed charges,,,11479.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5739.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8061.05,,,percent of total billed charges,,
PALIPERIDONE 234 MG IM,2500019908,CDM,636,RC,J2426,HCPCS,5045856401,NDC,9255,APC,,outpatient,facility,1.5,UN,11479.71,11479.71,14.14,4201.57,,,,,,,,15.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,14.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.88,,,fee schedule,,,,,,,,,4201.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,14.73,,,fee schedule,,,,,,,,,,,,,,,14.73,,,fee schedule,,,15.47,,,fee schedule,,,,,,,,,14.73,,,fee schedule,,,14.73,,,fee schedule,,,15.47,,,fee schedule,,,,,,,,,,,,,,,21.36,,,fee schedule,,,,,,,,,,,,,,,14.73,,,fee schedule,,,,,,,,,,,,,,,14.14,,,fee schedule,,,15.76,,,fee schedule,,,15.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.73,,,fee schedule,,,14.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,15.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,14.73,,,fee schedule,,,14.73,,,fee schedule,,,,,,,,,,,,,,,14.73,,,fee schedule,,,,,,,,,,,,,,,14.73,,,fee schedule,,,15.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.76,,,fee schedule,,,14.73,,,fee schedule,,,15.32,,,fee schedule,,,14.73,,,fee schedule,,,,,,,,,14.73,,,fee schedule,,,,,,,,,14.73,,,fee schedule,,,,,,,,
PALIPERIDONE 234 MG IM,2500019908,CDM,636,RC,J2426,HCPCS,5045856401,NDC,444,EAPG,,outpatient,facility,1.5,UN,11479.71,11479.71,1266.08,1856.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1856.07,,,fee schedule,,,1266.08,,,fee schedule,,,1650.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,1266.08,,,fee schedule,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PALIPERIDONE 156 MG IM,2500019909,CDM,636,RC,J2426,HCPCS,5045856301,NDC,,,,inpatient,facility,1,UN,7366.06,7366.06,589.28,7366.06,,,,,,,,,,,,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6629.45,,,percent of total billed charges,,,,,,,,,7366.06,,,percent of total billed charges,,,4077.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6720.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,7366.06,,,percent of total billed charges,,,3840.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1473.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,589.28,,,percent of total billed charges,,,7366.06,,,percent of total billed charges,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5172.45,,,percent of total billed charges,,
PALIPERIDONE 156 MG IM,2500019909,CDM,636,RC,J2426,HCPCS,5045856301,NDC,,,,outpatient,facility,1,UN,7366.06,7366.06,9.06,7366.06,,4301.78,,,percent of total billed charges,,,,,,,,,7366.06,,,percent of total billed charges,,,17.33,,,fee schedule,,,16.7,,,fee schedule,,,,,,,,,16.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6629.45,,,percent of total billed charges,,,,,,,,,7366.06,,,percent of total billed charges,,,4988.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5657.13,,,percent of total billed charges,,,,,,,,,,,,,,,14.32,,,fee schedule,,,14.32,,,fee schedule,,,,,,,,,618.77,,,per diem,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3840.66,,,percent of total billed charges,,,7366.06,,,percent of total billed charges,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5598.21,,,percent of total billed charges,,,2790.26,,,percent of total billed charges,,,3814.88,,,percent of total billed charges,,,,,,,,,,,,,,,1473.21,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,29.31,,,fee schedule,,,13.07,,,fee schedule,,,,,,,,,,,,,,,589.28,,,percent of total billed charges,,,7366.06,,,percent of total billed charges,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,7366.06,,,percent of total billed charges,,,7366.06,,,percent of total billed charges,,,,,,,,,7366.06,,,fee schedule,,,13.94,,,fee schedule,,,,,,,,,,,,,,,12.26,,,fee schedule,,,16.35,,,fee schedule,,,9.06,,,fee schedule,,,15.21,,,fee schedule,,,7366.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,7366.06,,,percent of total billed charges,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3683.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5172.45,,,percent of total billed charges,,
PALIPERIDONE 156 MG IM,2500019909,CDM,636,RC,J2426,HCPCS,5045856301,NDC,9255,APC,,outpatient,facility,1,UN,7366.06,7366.06,14.14,2695.98,,,,,,,,15.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,14.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.88,,,fee schedule,,,,,,,,,2695.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,14.73,,,fee schedule,,,,,,,,,,,,,,,14.73,,,fee schedule,,,15.47,,,fee schedule,,,,,,,,,14.73,,,fee schedule,,,14.73,,,fee schedule,,,15.47,,,fee schedule,,,,,,,,,,,,,,,21.36,,,fee schedule,,,,,,,,,,,,,,,14.73,,,fee schedule,,,,,,,,,,,,,,,14.14,,,fee schedule,,,15.76,,,fee schedule,,,15.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.73,,,fee schedule,,,14.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,15.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,14.73,,,fee schedule,,,14.73,,,fee schedule,,,,,,,,,,,,,,,14.73,,,fee schedule,,,,,,,,,,,,,,,14.73,,,fee schedule,,,15.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.76,,,fee schedule,,,14.73,,,fee schedule,,,15.32,,,fee schedule,,,14.73,,,fee schedule,,,,,,,,,14.73,,,fee schedule,,,,,,,,,14.73,,,fee schedule,,,,,,,,
PALIPERIDONE 156 MG IM,2500019909,CDM,636,RC,J2426,HCPCS,5045856301,NDC,444,EAPG,,outpatient,facility,1,UN,7366.06,7366.06,1266.08,1856.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1856.07,,,fee schedule,,,1266.08,,,fee schedule,,,1650.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,1266.08,,,fee schedule,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1266.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMMUNE GLOB IV 20 GM/GAMUNEX,2500019970,CDM,636,RC,J1561,HCPCS,1353380024,NDC,,,,inpatient,facility,200,ML,9355.5,9355.5,748.44,9355.5,,,,,,,,,,,,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8419.95,,,percent of total billed charges,,,,,,,,,9355.5,,,percent of total billed charges,,,5179.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8535.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,9355.5,,,percent of total billed charges,,,4877.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1871.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,748.44,,,percent of total billed charges,,,9355.5,,,percent of total billed charges,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6569.43,,,percent of total billed charges,,
IMMUNE GLOB IV 20 GM/GAMUNEX,2500019970,CDM,636,RC,J1561,HCPCS,1353380024,NDC,,,,outpatient,facility,200,ML,9355.5,9355.5,30.49,9355.5,,5463.61,,,percent of total billed charges,,,,,,,,,9355.5,,,percent of total billed charges,,,58.6,,,fee schedule,,,56.47,,,fee schedule,,,,,,,,,56.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,8419.95,,,percent of total billed charges,,,,,,,,,9355.5,,,percent of total billed charges,,,6335.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7185.02,,,percent of total billed charges,,,,,,,,,,,,,,,49.79,,,fee schedule,,,49.79,,,fee schedule,,,,,,,,,618.77,,,per diem,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4877.96,,,percent of total billed charges,,,9355.5,,,percent of total billed charges,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7110.18,,,percent of total billed charges,,,3543.86,,,percent of total billed charges,,,4845.21,,,percent of total billed charges,,,,,,,,,,,,,,,1871.1,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,98.59,,,fee schedule,,,43.96,,,fee schedule,,,,,,,,,,,,,,,748.44,,,percent of total billed charges,,,9355.5,,,percent of total billed charges,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,9355.5,,,percent of total billed charges,,,9355.5,,,percent of total billed charges,,,,,,,,,9355.5,,,fee schedule,,,46.9,,,fee schedule,,,,,,,,,,,,,,,41.24,,,fee schedule,,,54.99,,,fee schedule,,,30.49,,,fee schedule,,,51.45,,,fee schedule,,,9355.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9355.5,,,percent of total billed charges,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4677.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6569.43,,,percent of total billed charges,,
IMMUNE GLOB IV 20 GM/GAMUNEX,2500019970,CDM,636,RC,J1561,HCPCS,1353380024,NDC,948,APC,,outpatient,facility,200,ML,9355.5,9355.5,47.05,3424.11,,,,,,,,50.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,fee schedule,,,,,,,,,3424.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,49.01,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,49.01,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,,,,,,,,71.06,,,fee schedule,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,47.05,,,fee schedule,,,52.44,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,49.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,50.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,61.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,49.01,,,fee schedule,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,49.01,,,fee schedule,,,50.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.81,,,fee schedule,,,49.01,,,fee schedule,,,50.97,,,fee schedule,,,49.01,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,,,,,,
IMMUNE GLOB IV 20 GM/GAMUNEX,2500019970,CDM,636,RC,J1561,HCPCS,1353380024,NDC,460,EAPG,,outpatient,facility,200,ML,9355.5,9355.5,1557.16,2282.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2282.8,,,fee schedule,,,1557.16,,,fee schedule,,,2029.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,1557.16,,,fee schedule,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RHO(D) IMMUNE-RHOPHYLAC 1500IU,2500019980,CDM,636,RC,J2791,HCPCS,4420630001,NDC,,,,inpatient,facility,2,UN,545.13,545.13,43.61,545.13,,,,,,,,,,,,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.62,,,percent of total billed charges,,,,,,,,,545.13,,,percent of total billed charges,,,301.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,497.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,545.13,,,percent of total billed charges,,,284.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.61,,,percent of total billed charges,,,545.13,,,percent of total billed charges,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,382.79,,,percent of total billed charges,,
RHO(D) IMMUNE-RHOPHYLAC 1500IU,2500019980,CDM,636,RC,J2791,HCPCS,4420630001,NDC,,,,outpatient,facility,2,UN,545.13,545.13,4.94,618.77,,318.36,,,percent of total billed charges,,,106.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,545.13,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,199.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,490.62,,,percent of total billed charges,,,,,,,,,545.13,,,percent of total billed charges,,,369.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,284.23,,,percent of total billed charges,,,545.13,,,percent of total billed charges,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,414.3,,,percent of total billed charges,,,206.5,,,percent of total billed charges,,,282.32,,,percent of total billed charges,,,,,,,,,,,,,,,109.03,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,545.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,545.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.61,,,percent of total billed charges,,,545.13,,,percent of total billed charges,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,545.13,,,percent of total billed charges,,,545.13,,,percent of total billed charges,,,,,,,,,545.13,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.94,,,fee schedule,,,545.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,545.13,,,percent of total billed charges,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,382.79,,,percent of total billed charges,,
RHO(D) IMMUNE-RHOPHYLAC 1500IU,2500019980,CDM,636,RC,J2791,HCPCS,4420630001,NDC,436,EAPG,,outpatient,facility,2,UN,545.13,545.13,126.95,186.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.11,,,fee schedule,,,126.95,,,fee schedule,,,165.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.9  FLUSH 10ML,2500020101,CDM,250,RC,6332318610,NDC,,,,,,inpatient,facility,10,ML,3.36,3.36,0.27,3.36,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.02,,,percent of total billed charges,,,,,,,,,3.36,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,
SOD CHLORIDE 0.9  FLUSH 10ML,2500020101,CDM,250,RC,6332318610,NDC,,,,,,outpatient,facility,10,ML,3.36,3.36,0.27,618.77,,1.96,,,percent of total billed charges,,,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.36,,,percent of total billed charges,,,2.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.02,,,percent of total billed charges,,,,,,,,,3.36,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.34,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,3.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.27,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,3.36,,,fee schedule,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,3.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.36,,,percent of total billed charges,,
SOD CHLORIDE 0.9  FLUSH 10ML,2500020101,CDM,250,RC,6332318610,NDC,999,EAPG,,,,outpatient,facility,10,ML,3.36,3.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RANOLAZINE 500 MG TAB ER,2500020135,CDM,637,RC,7075670360,NDC,,,,,,inpatient,facility,500,UN,21.19,21.19,1.7,21.19,,,,,,,,,,,,,,21.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.07,,,percent of total billed charges,,,,,,,,,21.19,,,percent of total billed charges,,,11.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.19,,,percent of total billed charges,,,,,,,,,,,,,,,21.19,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,21.19,,,percent of total billed charges,,,21.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,
RANOLAZINE 500 MG TAB ER,2500020135,CDM,637,RC,7075670360,NDC,,,,,,outpatient,facility,500,UN,21.19,21.19,1.7,618.77,,12.37,,,percent of total billed charges,,,4.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,21.19,,,percent of total billed charges,,,18.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,18.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,18.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,21.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,19.07,,,percent of total billed charges,,,,,,,,,21.19,,,percent of total billed charges,,,14.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.27,,,percent of total billed charges,,,,,,,,,,,,,,,11.44,,,percent of total billed charges,,,11.44,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,21.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.05,,,percent of total billed charges,,,21.19,,,percent of total billed charges,,,21.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.1,,,percent of total billed charges,,,8.03,,,percent of total billed charges,,,10.97,,,percent of total billed charges,,,,,,,,,,,,,,,4.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.84,,,percent of total billed charges,,,7.84,,,percent of total billed charges,,,21.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.7,,,percent of total billed charges,,,21.19,,,percent of total billed charges,,,21.19,,,percent of total billed charges,,,,,,,,,,,,,,,21.19,,,percent of total billed charges,,,21.19,,,percent of total billed charges,,,,,,,,,21.19,,,fee schedule,,,19.71,,,percent of total billed charges,,,,,,,,,,,,,,,19.71,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,15.89,,,percent of total billed charges,,,21.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,21.19,,,percent of total billed charges,,,21.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,14.88,,,percent of total billed charges,,
RANOLAZINE 500 MG TAB ER,2500020135,CDM,637,RC,7075670360,NDC,999,EAPG,,,,outpatient,facility,500,UN,21.19,21.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REGADENOSON 0.4 MG INJ,2500020248,CDM,636,RC,J2785,HCPCS,7632933210,NDC,,,,inpatient,facility,5,UN,99,99,7.92,99,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,,,,,,,99,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,51.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.52,,,percent of total billed charges,,
REGADENOSON 0.4 MG INJ,2500020248,CDM,636,RC,J2785,HCPCS,7632933210,NDC,,,,outpatient,facility,5,UN,99,99,3.52,618.77,,57.82,,,percent of total billed charges,,,19.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,99,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,36.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,89.1,,,percent of total billed charges,,,,,,,,,99,,,percent of total billed charges,,,67.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.03,,,percent of total billed charges,,,,,,,,,,,,,,,14.28,,,fee schedule,,,14.28,,,fee schedule,,,,,,,,,618.77,,,per diem,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.62,,,percent of total billed charges,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.24,,,percent of total billed charges,,,37.5,,,percent of total billed charges,,,51.27,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.92,,,percent of total billed charges,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,99,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.52,,,fee schedule,,,99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,69.52,,,percent of total billed charges,,
REGADENOSON 0.4 MG INJ,2500020248,CDM,636,RC,J2785,HCPCS,7632933210,NDC,2000,EAPG,,outpatient,facility,5,UN,99,99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DESVENLAFAXINE 50 MG,2500020249,CDM,637,RC,6330419130,NDC,,,,,,inpatient,facility,50,UN,15.31,15.31,1.22,15.31,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.78,,,percent of total billed charges,,,,,,,,,15.31,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.75,,,percent of total billed charges,,
DESVENLAFAXINE 50 MG,2500020249,CDM,637,RC,6330419130,NDC,,,,,,outpatient,facility,50,UN,15.31,15.31,1.22,618.77,,8.94,,,percent of total billed charges,,,2.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,15.31,,,percent of total billed charges,,,13.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,13.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,13.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,13.78,,,percent of total billed charges,,,,,,,,,15.31,,,percent of total billed charges,,,10.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,8.27,,,percent of total billed charges,,,8.27,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.64,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,7.93,,,percent of total billed charges,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.66,,,percent of total billed charges,,,5.66,,,percent of total billed charges,,,15.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.22,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,15.31,,,fee schedule,,,14.24,,,percent of total billed charges,,,,,,,,,,,,,,,14.24,,,percent of total billed charges,,,14.24,,,percent of total billed charges,,,14.24,,,percent of total billed charges,,,11.48,,,percent of total billed charges,,,15.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,15.31,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.75,,,percent of total billed charges,,
DESVENLAFAXINE 50 MG,2500020249,CDM,637,RC,6330419130,NDC,999,EAPG,,,,outpatient,facility,50,UN,15.31,15.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLNALTREXONE 12MG/.6ML INJ,2500020250,CDM,636,RC,J2212,HCPCS,6564955102,NDC,,,,inpatient,facility,0.6,UN,529.02,529.02,42.32,529.02,,,,,,,,,,,,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.12,,,percent of total billed charges,,,,,,,,,529.02,,,percent of total billed charges,,,292.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,529.02,,,percent of total billed charges,,,275.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.32,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.48,,,percent of total billed charges,,
METHYLNALTREXONE 12MG/.6ML INJ,2500020250,CDM,636,RC,J2212,HCPCS,6564955102,NDC,,,,outpatient,facility,0.6,UN,529.02,529.02,0.94,618.77,,308.95,,,percent of total billed charges,,,103.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,529.02,,,percent of total billed charges,,,1.8,,,fee schedule,,,1.73,,,fee schedule,,,,,,,,,1.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,193.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,476.12,,,percent of total billed charges,,,,,,,,,529.02,,,percent of total billed charges,,,358.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.29,,,percent of total billed charges,,,,,,,,,,,,,,,1.31,,,fee schedule,,,1.31,,,fee schedule,,,,,,,,,618.77,,,per diem,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,275.83,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.06,,,percent of total billed charges,,,200.39,,,percent of total billed charges,,,273.98,,,percent of total billed charges,,,,,,,,,,,,,,,105.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,529.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,529.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,42.32,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,529.02,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,,,,,,,529.02,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,396.76,,,percent of total billed charges,,,529.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,529.02,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,0.94,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,371.48,,,percent of total billed charges,,
METHYLNALTREXONE 12MG/.6ML INJ,2500020250,CDM,636,RC,J2212,HCPCS,6564955102,NDC,435,EAPG,,outpatient,facility,0.6,UN,529.02,529.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RASAGILINE 1 MG TAB,2500020252,CDM,637,RC,6787726030,NDC,,,,,,inpatient,facility,1,UN,82.43,82.43,6.59,82.43,,,,,,,,,,,,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.19,,,percent of total billed charges,,,,,,,,,82.43,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,82.43,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.59,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.88,,,percent of total billed charges,,
RASAGILINE 1 MG TAB,2500020252,CDM,637,RC,6787726030,NDC,,,,,,outpatient,facility,1,UN,82.43,82.43,6.59,618.77,,48.14,,,percent of total billed charges,,,16.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,82.43,,,percent of total billed charges,,,72.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,72.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,72.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,30.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,74.19,,,percent of total billed charges,,,,,,,,,82.43,,,percent of total billed charges,,,55.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.31,,,percent of total billed charges,,,,,,,,,,,,,,,44.51,,,percent of total billed charges,,,44.51,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.98,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.65,,,percent of total billed charges,,,31.22,,,percent of total billed charges,,,42.69,,,percent of total billed charges,,,,,,,,,,,,,,,16.49,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,30.5,,,percent of total billed charges,,,30.5,,,percent of total billed charges,,,82.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,82.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.59,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,82.43,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,,,,,,,82.43,,,fee schedule,,,76.68,,,percent of total billed charges,,,,,,,,,,,,,,,76.68,,,percent of total billed charges,,,76.68,,,percent of total billed charges,,,76.68,,,percent of total billed charges,,,61.82,,,percent of total billed charges,,,82.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,82.43,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,57.88,,,percent of total billed charges,,
RASAGILINE 1 MG TAB,2500020252,CDM,637,RC,6787726030,NDC,999,EAPG,,,,outpatient,facility,1,UN,82.43,82.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MICAFUNGIN 100 MG INJ,2500020265,CDM,636,RC,J2248,HCPCS,469321110,NDC,,,,inpatient,facility,100,UN,617.1,617.1,49.37,617.1,,,,,,,,,,,,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.39,,,percent of total billed charges,,,,,,,,,617.1,,,percent of total billed charges,,,341.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,563.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,617.1,,,percent of total billed charges,,,321.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.37,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.33,,,percent of total billed charges,,
MICAFUNGIN 100 MG INJ,2500020265,CDM,636,RC,J2248,HCPCS,469321110,NDC,,,,outpatient,facility,100,UN,617.1,617.1,0.44,618.77,,360.39,,,percent of total billed charges,,,120.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,617.1,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,225.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,555.39,,,percent of total billed charges,,,,,,,,,617.1,,,percent of total billed charges,,,417.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,321.76,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,469,,,percent of total billed charges,,,233.76,,,percent of total billed charges,,,319.6,,,percent of total billed charges,,,,,,,,,,,,,,,123.42,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,617.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,617.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,49.37,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,617.1,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,,,,,,,617.1,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.44,,,fee schedule,,,617.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,617.1,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,433.33,,,percent of total billed charges,,
MICAFUNGIN 100 MG INJ,2500020265,CDM,636,RC,J2248,HCPCS,469321110,NDC,435,EAPG,,outpatient,facility,100,UN,617.1,617.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DRONEDARONE,2500020268,CDM,637,RC,24414260,NDC,,,,,,inpatient,facility,400,UN,43.89,43.89,3.51,43.89,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.5,,,percent of total billed charges,,,,,,,,,43.89,,,percent of total billed charges,,,24.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,22.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.82,,,percent of total billed charges,,
DRONEDARONE,2500020268,CDM,637,RC,24414260,NDC,,,,,,outpatient,facility,400,UN,43.89,43.89,3.51,618.77,,25.63,,,percent of total billed charges,,,8.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,43.89,,,percent of total billed charges,,,38.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,38.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,38.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,39.5,,,percent of total billed charges,,,,,,,,,43.89,,,percent of total billed charges,,,29.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.71,,,percent of total billed charges,,,,,,,,,,,,,,,23.7,,,percent of total billed charges,,,23.7,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.88,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.36,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,22.73,,,percent of total billed charges,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,16.24,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,43.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.51,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,43.89,,,fee schedule,,,40.83,,,percent of total billed charges,,,,,,,,,,,,,,,40.83,,,percent of total billed charges,,,40.83,,,percent of total billed charges,,,40.83,,,percent of total billed charges,,,32.92,,,percent of total billed charges,,,43.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,43.89,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,30.82,,,percent of total billed charges,,
DRONEDARONE,2500020268,CDM,637,RC,24414260,NDC,999,EAPG,,,,outpatient,facility,400,UN,43.89,43.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRASUGREL 10 MG,2500020269,CDM,637,RC,5140724830,NDC,,,,,,inpatient,facility,10,UN,2.51,2.51,0.2,2.51,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,2.51,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,
PRASUGREL 10 MG,2500020269,CDM,637,RC,5140724830,NDC,,,,,,outpatient,facility,10,UN,2.51,2.51,0.2,618.77,,1.47,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.51,,,percent of total billed charges,,,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.26,,,percent of total billed charges,,,,,,,,,2.51,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.93,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,2.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,2.51,,,fee schedule,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,2.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.76,,,percent of total billed charges,,
PRASUGREL 10 MG,2500020269,CDM,637,RC,5140724830,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.51,2.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FERUMOXYTOL 510MG INJ NON-ESRD,2500020282,CDM,636,RC,Q0138,HCPCS,5933877501,NDC,,,,inpatient,facility,17,ML,3938.95,3938.95,315.12,3938.95,,,,,,,,,,,,,,3938.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3545.05,,,percent of total billed charges,,,,,,,,,3938.95,,,percent of total billed charges,,,2180.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3593.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3938.95,,,percent of total billed charges,,,,,,,,,,,,,,,3938.95,,,percent of total billed charges,,,2053.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.12,,,percent of total billed charges,,,3938.95,,,percent of total billed charges,,,3938.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3938.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2765.93,,,percent of total billed charges,,
FERUMOXYTOL 510MG INJ NON-ESRD,2500020282,CDM,636,RC,Q0138,HCPCS,5933877501,NDC,,,,outpatient,facility,17,ML,3938.95,3938.95,0.34,3938.95,,2300.35,,,percent of total billed charges,,,,,,,,,3938.95,,,percent of total billed charges,,,0.39,,,fee schedule,,,0.38,,,fee schedule,,,,,,,,,0.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3938.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3545.05,,,percent of total billed charges,,,,,,,,,3938.95,,,percent of total billed charges,,,2667.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3025.11,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,fee schedule,,,0.36,,,fee schedule,,,,,,,,,618.77,,,per diem,,,3938.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2053.77,,,percent of total billed charges,,,3938.95,,,percent of total billed charges,,,3938.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2993.6,,,percent of total billed charges,,,1492.07,,,percent of total billed charges,,,2039.98,,,percent of total billed charges,,,,,,,,,,,,,,,787.79,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.17,,,fee schedule,,,0.52,,,fee schedule,,,,,,,,,,,,,,,315.12,,,percent of total billed charges,,,3938.95,,,percent of total billed charges,,,3938.95,,,percent of total billed charges,,,,,,,,,,,,,,,3938.95,,,percent of total billed charges,,,3938.95,,,percent of total billed charges,,,,,,,,,3938.95,,,fee schedule,,,0.56,,,fee schedule,,,,,,,,,,,,,,,0.49,,,fee schedule,,,0.65,,,fee schedule,,,0.36,,,fee schedule,,,0.34,,,fee schedule,,,3938.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3938.95,,,percent of total billed charges,,,3938.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1969.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2765.93,,,percent of total billed charges,,
FERUMOXYTOL 510MG INJ NON-ESRD,2500020282,CDM,636,RC,Q0138,HCPCS,5933877501,NDC,1297,APC,,outpatient,facility,17,ML,3938.95,3938.95,0.34,1441.66,,,,,,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,fee schedule,,,,,,,,,1441.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.38,,,fee schedule,,,,,,,,,,,,,,,0.38,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,0.38,,,fee schedule,,,0.38,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.55,,,fee schedule,,,,,,,,,,,,,,,0.38,,,fee schedule,,,,,,,,,,,,,,,0.36,,,fee schedule,,,0.41,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,fee schedule,,,0.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.38,,,fee schedule,,,0.38,,,fee schedule,,,,,,,,,,,,,,,0.38,,,fee schedule,,,,,,,,,,,,,,,0.38,,,fee schedule,,,0.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,fee schedule,,,0.38,,,fee schedule,,,0.4,,,fee schedule,,,0.38,,,fee schedule,,,,,,,,,0.38,,,fee schedule,,,,,,,,,0.38,,,fee schedule,,,,,,,,
FERUMOXYTOL 510MG INJ NON-ESRD,2500020282,CDM,636,RC,Q0138,HCPCS,5933877501,NDC,438,EAPG,,outpatient,facility,17,ML,3938.95,3938.95,323.15,473.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.74,,,fee schedule,,,323.15,,,fee schedule,,,421.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VITAMIN D 1000 IU TAB,2500020286,CDM,637,RC,2055503300,NDC,,,,,,inpatient,facility,1000,UN,1.42,1.42,0.11,1.42,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,
VITAMIN D 1000 IU TAB,2500020286,CDM,637,RC,2055503300,NDC,,,,,,outpatient,facility,1000,UN,1.42,1.42,0.11,618.77,,0.83,,,percent of total billed charges,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.42,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.28,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,1.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,1.42,,,fee schedule,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,1.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1,,,percent of total billed charges,,
VITAMIN D 1000 IU TAB,2500020286,CDM,637,RC,2055503300,NDC,999,EAPG,,,,outpatient,facility,1000,UN,1.42,1.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUTEROL SULF INH SOL.042 3ML,2500020287,CDM,637,RC,487990425,NDC,,,,,,inpatient,facility,3,UN,5.48,5.48,0.44,5.48,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.93,,,percent of total billed charges,,,,,,,,,5.48,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,
ALBUTEROL SULF INH SOL.042 3ML,2500020287,CDM,637,RC,487990425,NDC,,,,,,outpatient,facility,3,UN,5.48,5.48,0.44,618.77,,3.2,,,percent of total billed charges,,,1.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.48,,,percent of total billed charges,,,4.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.93,,,percent of total billed charges,,,,,,,,,5.48,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,,2.96,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,5.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.44,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,5.48,,,fee schedule,,,5.1,,,percent of total billed charges,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,5.1,,,percent of total billed charges,,,5.1,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,5.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.48,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.85,,,percent of total billed charges,,
ALBUTEROL SULF INH SOL.042 3ML,2500020287,CDM,637,RC,487990425,NDC,999,EAPG,,,,outpatient,facility,3,UN,5.48,5.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOCOSANOL 10  CR 2 GM TUBE,2500031735,CDM,637,RC,135020001,NDC,,,,,,inpatient,facility,2,UN,51.02,51.02,4.08,51.02,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.92,,,percent of total billed charges,,,,,,,,,51.02,,,percent of total billed charges,,,28.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,26.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.08,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.83,,,percent of total billed charges,,
DOCOSANOL 10  CR 2 GM TUBE,2500031735,CDM,637,RC,135020001,NDC,,,,,,outpatient,facility,2,UN,51.02,51.02,4.08,618.77,,29.8,,,percent of total billed charges,,,9.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,51.02,,,percent of total billed charges,,,44.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,44.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,44.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,18.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,45.92,,,percent of total billed charges,,,,,,,,,51.02,,,percent of total billed charges,,,34.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.18,,,percent of total billed charges,,,,,,,,,,,,,,,27.55,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.6,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.78,,,percent of total billed charges,,,19.33,,,percent of total billed charges,,,26.42,,,percent of total billed charges,,,,,,,,,,,,,,,10.2,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,18.88,,,percent of total billed charges,,,18.88,,,percent of total billed charges,,,51.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.08,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,51.02,,,fee schedule,,,47.46,,,percent of total billed charges,,,,,,,,,,,,,,,47.46,,,percent of total billed charges,,,47.46,,,percent of total billed charges,,,47.46,,,percent of total billed charges,,,38.27,,,percent of total billed charges,,,51.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.83,,,percent of total billed charges,,
DOCOSANOL 10  CR 2 GM TUBE,2500031735,CDM,637,RC,135020001,NDC,999,EAPG,,,,outpatient,facility,2,UN,51.02,51.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUDESONIDE/FORMOT 80-4.5 INH,2500031746,CDM,637,RC,J3535,HCPCS,310737220,NDC,,,,inpatient,facility,10.2,UN,1163.32,1163.32,93.07,1163.32,,,,,,,,,,,,,,1163.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1046.99,,,percent of total billed charges,,,,,,,,,1163.32,,,percent of total billed charges,,,644.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1061.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.32,,,percent of total billed charges,,,,,,,,,,,,,,,1163.32,,,percent of total billed charges,,,606.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.07,,,percent of total billed charges,,,1163.32,,,percent of total billed charges,,,1163.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1163.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,816.88,,,percent of total billed charges,,
BUDESONIDE/FORMOT 80-4.5 INH,2500031746,CDM,637,RC,J3535,HCPCS,310737220,NDC,,,,outpatient,facility,10.2,UN,1163.32,1163.32,2.48,1163.32,,679.38,,,percent of total billed charges,,,226.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1163.32,,,percent of total billed charges,,,1024.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1024.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1024.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1163.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,425.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1046.99,,,percent of total billed charges,,,,,,,,,1163.32,,,percent of total billed charges,,,787.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,893.43,,,percent of total billed charges,,,,,,,,,,,,,,,628.19,,,percent of total billed charges,,,628.19,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1163.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,606.56,,,percent of total billed charges,,,1163.32,,,percent of total billed charges,,,1163.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,884.12,,,percent of total billed charges,,,440.67,,,percent of total billed charges,,,602.48,,,percent of total billed charges,,,,,,,,,,,,,,,232.66,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.03,,,fee schedule,,,3.58,,,fee schedule,,,1163.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1163.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,93.07,,,percent of total billed charges,,,1163.32,,,percent of total billed charges,,,1163.32,,,percent of total billed charges,,,,,,,,,,,,,,,1163.32,,,percent of total billed charges,,,1163.32,,,percent of total billed charges,,,,,,,,,1163.32,,,fee schedule,,,3.82,,,fee schedule,,,,,,,,,,,,,,,3.36,,,fee schedule,,,4.48,,,fee schedule,,,2.48,,,fee schedule,,,872.49,,,percent of total billed charges,,,1163.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1163.32,,,percent of total billed charges,,,1163.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,581.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,816.88,,,percent of total billed charges,,
BUDESONIDE/FORMOT 80-4.5 INH,2500031746,CDM,637,RC,J3535,HCPCS,310737220,NDC,999,EAPG,,outpatient,facility,10.2,UN,1163.32,1163.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRINE 400MCG/10 ML SYR,2500031756,CDM,636,RC,J2371,HCPCS,7128660071,NDC,,,,inpatient,facility,10,UN,14.03,14.03,1.12,14.03,,,,,,,,,,,,,,14.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.63,,,percent of total billed charges,,,,,,,,,14.03,,,percent of total billed charges,,,7.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.03,,,percent of total billed charges,,,,,,,,,,,,,,,14.03,,,percent of total billed charges,,,7.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,14.03,,,percent of total billed charges,,,14.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.85,,,percent of total billed charges,,
PHENYLEPHRINE 400MCG/10 ML SYR,2500031756,CDM,636,RC,J2371,HCPCS,7128660071,NDC,,,,outpatient,facility,10,UN,14.03,14.03,1.12,618.77,,8.19,,,percent of total billed charges,,,2.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.03,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,14.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.63,,,percent of total billed charges,,,,,,,,,14.03,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,14.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.32,,,percent of total billed charges,,,14.03,,,percent of total billed charges,,,14.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.66,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,7.27,,,percent of total billed charges,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,14.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.12,,,percent of total billed charges,,,14.03,,,percent of total billed charges,,,14.03,,,percent of total billed charges,,,,,,,,,,,,,,,14.03,,,percent of total billed charges,,,14.03,,,percent of total billed charges,,,,,,,,,14.03,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,10.52,,,percent of total billed charges,,,14.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.03,,,percent of total billed charges,,,14.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.85,,,percent of total billed charges,,
PHENYLEPHRINE 400MCG/10 ML SYR,2500031756,CDM,636,RC,J2371,HCPCS,7128660071,NDC,999,EAPG,,outpatient,facility,10,UN,14.03,14.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIFAXIMIN 550 MG TAB,2500031757,CDM,637,RC,6564930303,NDC,,,,,,inpatient,facility,550,UN,179.69,179.69,14.38,179.69,,,,,,,,,,,,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.72,,,percent of total billed charges,,,,,,,,,179.69,,,percent of total billed charges,,,99.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,179.69,,,percent of total billed charges,,,93.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.38,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.18,,,percent of total billed charges,,
RIFAXIMIN 550 MG TAB,2500031757,CDM,637,RC,6564930303,NDC,,,,,,outpatient,facility,550,UN,179.69,179.69,14.38,618.77,,104.94,,,percent of total billed charges,,,35.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,179.69,,,percent of total billed charges,,,158.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,158.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,158.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,65.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,161.72,,,percent of total billed charges,,,,,,,,,179.69,,,percent of total billed charges,,,121.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138,,,percent of total billed charges,,,,,,,,,,,,,,,97.03,,,percent of total billed charges,,,97.03,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93.69,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.56,,,percent of total billed charges,,,68.07,,,percent of total billed charges,,,93.06,,,percent of total billed charges,,,,,,,,,,,,,,,35.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,66.49,,,percent of total billed charges,,,66.49,,,percent of total billed charges,,,179.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,179.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.38,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,179.69,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,,,,,,,179.69,,,fee schedule,,,167.15,,,percent of total billed charges,,,,,,,,,,,,,,,167.15,,,percent of total billed charges,,,167.15,,,percent of total billed charges,,,167.15,,,percent of total billed charges,,,134.77,,,percent of total billed charges,,,179.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,179.69,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,126.18,,,percent of total billed charges,,
RIFAXIMIN 550 MG TAB,2500031757,CDM,637,RC,6564930303,NDC,999,EAPG,,,,outpatient,facility,550,UN,179.69,179.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRINE 100MG/10ML IV,2500031761,CDM,636,RC,J2371,HCPCS,5515030201,NDC,,,,inpatient,facility,10,ML,148.5,148.5,11.88,148.5,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.65,,,percent of total billed charges,,,,,,,,,148.5,,,percent of total billed charges,,,82.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,77.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.28,,,percent of total billed charges,,
PHENYLEPHRINE 100MG/10ML IV,2500031761,CDM,636,RC,J2371,HCPCS,5515030201,NDC,,,,outpatient,facility,10,ML,148.5,148.5,11.88,618.77,,86.72,,,percent of total billed charges,,,28.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,148.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,54.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,133.65,,,percent of total billed charges,,,,,,,,,148.5,,,percent of total billed charges,,,100.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.43,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.86,,,percent of total billed charges,,,56.25,,,percent of total billed charges,,,76.91,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,148.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,148.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.88,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,,,,,,,148.5,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,111.38,,,percent of total billed charges,,,148.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,148.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,104.28,,,percent of total billed charges,,
PHENYLEPHRINE 100MG/10ML IV,2500031761,CDM,636,RC,J2371,HCPCS,5515030201,NDC,999,EAPG,,outpatient,facility,10,ML,148.5,148.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPHET ASP/AMPH/D-AMPH 10 MG,2500031762,CDM,637,RC,4778117601,NDC,,,,,,inpatient,facility,10,UN,5.64,5.64,0.45,5.64,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,,,,,,,5.64,,,percent of total billed charges,,,3.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,
AMPHET ASP/AMPH/D-AMPH 10 MG,2500031762,CDM,637,RC,4778117601,NDC,,,,,,outpatient,facility,10,UN,5.64,5.64,0.45,618.77,,3.29,,,percent of total billed charges,,,1.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.64,,,percent of total billed charges,,,4.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.08,,,percent of total billed charges,,,,,,,,,5.64,,,percent of total billed charges,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.33,,,percent of total billed charges,,,,,,,,,,,,,,,3.05,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.29,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.09,,,percent of total billed charges,,,2.09,,,percent of total billed charges,,,5.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.45,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,,,,,,,5.64,,,fee schedule,,,5.25,,,percent of total billed charges,,,,,,,,,,,,,,,5.25,,,percent of total billed charges,,,5.25,,,percent of total billed charges,,,5.25,,,percent of total billed charges,,,4.23,,,percent of total billed charges,,,5.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.64,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.96,,,percent of total billed charges,,
AMPHET ASP/AMPH/D-AMPH 10 MG,2500031762,CDM,637,RC,4778117601,NDC,999,EAPG,,,,outpatient,facility,10,UN,5.64,5.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESALAMINE 1.2 GM TABCR,2500031769,CDM,637,RC,5409247612,NDC,,,,,,inpatient,facility,1.2,UN,30.88,30.88,2.47,30.88,,,,,,,,,,,,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.79,,,percent of total billed charges,,,,,,,,,30.88,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,30.88,,,percent of total billed charges,,,16.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.68,,,percent of total billed charges,,
MESALAMINE 1.2 GM TABCR,2500031769,CDM,637,RC,5409247612,NDC,,,,,,outpatient,facility,1.2,UN,30.88,30.88,2.47,618.77,,18.03,,,percent of total billed charges,,,6.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,30.88,,,percent of total billed charges,,,27.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,27.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,27.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,27.79,,,percent of total billed charges,,,,,,,,,30.88,,,percent of total billed charges,,,20.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.72,,,percent of total billed charges,,,,,,,,,,,,,,,16.68,,,percent of total billed charges,,,16.68,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.1,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.47,,,percent of total billed charges,,,11.7,,,percent of total billed charges,,,15.99,,,percent of total billed charges,,,,,,,,,,,,,,,6.18,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,11.43,,,percent of total billed charges,,,11.43,,,percent of total billed charges,,,30.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.47,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,30.88,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,,,,,,,30.88,,,fee schedule,,,28.72,,,percent of total billed charges,,,,,,,,,,,,,,,28.72,,,percent of total billed charges,,,28.72,,,percent of total billed charges,,,28.72,,,percent of total billed charges,,,23.16,,,percent of total billed charges,,,30.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,30.88,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,21.68,,,percent of total billed charges,,
MESALAMINE 1.2 GM TABCR,2500031769,CDM,637,RC,5409247612,NDC,999,EAPG,,,,outpatient,facility,1.2,UN,30.88,30.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SELENIUM SULF 1  SHAMP 210ML,2500031783,CDM,637,RC,536199553,NDC,,,,,,inpatient,facility,207,UN,9.54,9.54,0.76,9.54,,,,,,,,,,,,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.59,,,percent of total billed charges,,,,,,,,,9.54,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,9.54,,,percent of total billed charges,,,4.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,
SELENIUM SULF 1  SHAMP 210ML,2500031783,CDM,637,RC,536199553,NDC,,,,,,outpatient,facility,207,UN,9.54,9.54,0.76,618.77,,5.57,,,percent of total billed charges,,,1.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.54,,,percent of total billed charges,,,8.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,8.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,8.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.59,,,percent of total billed charges,,,,,,,,,9.54,,,percent of total billed charges,,,6.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.33,,,percent of total billed charges,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.97,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,3.61,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,9.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.76,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,9.54,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,,,,,,,9.54,,,fee schedule,,,8.87,,,percent of total billed charges,,,,,,,,,,,,,,,8.87,,,percent of total billed charges,,,8.87,,,percent of total billed charges,,,8.87,,,percent of total billed charges,,,7.15,,,percent of total billed charges,,,9.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.54,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.7,,,percent of total billed charges,,
SELENIUM SULF 1  SHAMP 210ML,2500031783,CDM,637,RC,536199553,NDC,999,EAPG,,,,outpatient,facility,207,UN,9.54,9.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SALIVA SUBSTITUTE 45 ML,2500031789,CDM,637,RC,4858200155,NDC,,,,,,inpatient,facility,44.3,UN,8.43,8.43,0.67,8.43,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,8.43,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.92,,,percent of total billed charges,,
SALIVA SUBSTITUTE 45 ML,2500031789,CDM,637,RC,4858200155,NDC,,,,,,outpatient,facility,44.3,UN,8.43,8.43,0.67,618.77,,4.92,,,percent of total billed charges,,,1.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.43,,,percent of total billed charges,,,7.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.59,,,percent of total billed charges,,,,,,,,,8.43,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.47,,,percent of total billed charges,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.4,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.41,,,percent of total billed charges,,,3.19,,,percent of total billed charges,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.12,,,percent of total billed charges,,,3.12,,,percent of total billed charges,,,8.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.67,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,,,,,,,8.43,,,fee schedule,,,7.84,,,percent of total billed charges,,,,,,,,,,,,,,,7.84,,,percent of total billed charges,,,7.84,,,percent of total billed charges,,,7.84,,,percent of total billed charges,,,6.32,,,percent of total billed charges,,,8.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.43,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5.92,,,percent of total billed charges,,
SALIVA SUBSTITUTE 45 ML,2500031789,CDM,637,RC,4858200155,NDC,999,EAPG,,,,outpatient,facility,44.3,UN,8.43,8.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPHEDRINE 50 MG/10 ML SYR,2500031794,CDM,250,RC,4202321625,NDC,,,,,,inpatient,facility,10,UN,187.28,187.28,14.98,187.28,,,,,,,,,,,,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.55,,,percent of total billed charges,,,,,,,,,187.28,,,percent of total billed charges,,,103.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,187.28,,,percent of total billed charges,,,97.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.51,,,percent of total billed charges,,
EPHEDRINE 50 MG/10 ML SYR,2500031794,CDM,250,RC,4202321625,NDC,,,,,,outpatient,facility,10,UN,187.28,187.28,14.98,618.77,,109.37,,,percent of total billed charges,,,36.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,187.28,,,percent of total billed charges,,,164.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,164.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,164.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,68.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,168.55,,,percent of total billed charges,,,,,,,,,187.28,,,percent of total billed charges,,,126.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,97.65,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.33,,,percent of total billed charges,,,70.94,,,percent of total billed charges,,,96.99,,,percent of total billed charges,,,,,,,,,,,,,,,37.46,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,74.91,,,percent of total billed charges,,,74.91,,,percent of total billed charges,,,187.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,187.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.98,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,187.28,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,,,,,,,187.28,,,fee schedule,,,74.91,,,percent of total billed charges,,,,,,,,,,,,,,,74.91,,,percent of total billed charges,,,74.91,,,percent of total billed charges,,,74.91,,,percent of total billed charges,,,140.46,,,percent of total billed charges,,,187.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,187.28,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,131.51,,,percent of total billed charges,,
EPHEDRINE 50 MG/10 ML SYR,2500031794,CDM,250,RC,4202321625,NDC,999,EAPG,,,,outpatient,facility,10,UN,187.28,187.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DABIGATRANETEXILATE 150 MG CAP,2500031796,CDM,637,RC,597036082,NDC,,,,,,inpatient,facility,150,UN,10.92,10.92,0.87,10.92,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.83,,,percent of total billed charges,,,,,,,,,10.92,,,percent of total billed charges,,,6.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,5.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.67,,,percent of total billed charges,,
DABIGATRANETEXILATE 150 MG CAP,2500031796,CDM,637,RC,597036082,NDC,,,,,,outpatient,facility,150,UN,10.92,10.92,0.87,618.77,,6.38,,,percent of total billed charges,,,2.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.92,,,percent of total billed charges,,,9.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,9.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,9.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.83,,,percent of total billed charges,,,,,,,,,10.92,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.39,,,percent of total billed charges,,,,,,,,,,,,,,,5.9,,,percent of total billed charges,,,5.9,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.69,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.3,,,percent of total billed charges,,,4.14,,,percent of total billed charges,,,5.66,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.04,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,10.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.87,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,10.92,,,fee schedule,,,10.16,,,percent of total billed charges,,,,,,,,,,,,,,,10.16,,,percent of total billed charges,,,10.16,,,percent of total billed charges,,,10.16,,,percent of total billed charges,,,8.19,,,percent of total billed charges,,,10.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.67,,,percent of total billed charges,,
DABIGATRANETEXILATE 150 MG CAP,2500031796,CDM,637,RC,597036082,NDC,999,EAPG,,,,outpatient,facility,150,UN,10.92,10.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACOSAMIDE 200 MG TAB,2500031798,CDM,637,RC,131248060,NDC,,,,,,inpatient,facility,200,UN,70.82,70.82,5.67,70.82,,,,,,,,,,,,,,70.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.74,,,percent of total billed charges,,,,,,,,,70.82,,,percent of total billed charges,,,39.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.82,,,percent of total billed charges,,,,,,,,,,,,,,,70.82,,,percent of total billed charges,,,36.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,70.82,,,percent of total billed charges,,,70.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.73,,,percent of total billed charges,,
LACOSAMIDE 200 MG TAB,2500031798,CDM,637,RC,131248060,NDC,,,,,,outpatient,facility,200,UN,70.82,70.82,5.67,618.77,,41.36,,,percent of total billed charges,,,13.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,70.82,,,percent of total billed charges,,,62.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,62.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,62.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,70.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,25.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,63.74,,,percent of total billed charges,,,,,,,,,70.82,,,percent of total billed charges,,,47.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.39,,,percent of total billed charges,,,,,,,,,,,,,,,38.24,,,percent of total billed charges,,,38.24,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,70.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.93,,,percent of total billed charges,,,70.82,,,percent of total billed charges,,,70.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.82,,,percent of total billed charges,,,26.83,,,percent of total billed charges,,,36.68,,,percent of total billed charges,,,,,,,,,,,,,,,14.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,26.2,,,percent of total billed charges,,,26.2,,,percent of total billed charges,,,70.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,70.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.67,,,percent of total billed charges,,,70.82,,,percent of total billed charges,,,70.82,,,percent of total billed charges,,,,,,,,,,,,,,,70.82,,,percent of total billed charges,,,70.82,,,percent of total billed charges,,,,,,,,,70.82,,,fee schedule,,,65.88,,,percent of total billed charges,,,,,,,,,,,,,,,65.88,,,percent of total billed charges,,,65.88,,,percent of total billed charges,,,65.88,,,percent of total billed charges,,,53.11,,,percent of total billed charges,,,70.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,70.82,,,percent of total billed charges,,,70.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,49.73,,,percent of total billed charges,,
LACOSAMIDE 200 MG TAB,2500031798,CDM,637,RC,131248060,NDC,999,EAPG,,,,outpatient,facility,200,UN,70.82,70.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DABIGATRAN 75 MG CAPS,2500031809,CDM,637,RC,597035556,NDC,,,,,,inpatient,facility,75,UN,10.92,10.92,0.87,10.92,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.83,,,percent of total billed charges,,,,,,,,,10.92,,,percent of total billed charges,,,6.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,5.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.67,,,percent of total billed charges,,
DABIGATRAN 75 MG CAPS,2500031809,CDM,637,RC,597035556,NDC,,,,,,outpatient,facility,75,UN,10.92,10.92,0.87,618.77,,6.38,,,percent of total billed charges,,,2.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.92,,,percent of total billed charges,,,9.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,9.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,9.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.83,,,percent of total billed charges,,,,,,,,,10.92,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.39,,,percent of total billed charges,,,,,,,,,,,,,,,5.9,,,percent of total billed charges,,,5.9,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.69,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.3,,,percent of total billed charges,,,4.14,,,percent of total billed charges,,,5.66,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.04,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,10.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.87,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,10.92,,,fee schedule,,,10.16,,,percent of total billed charges,,,,,,,,,,,,,,,10.16,,,percent of total billed charges,,,10.16,,,percent of total billed charges,,,10.16,,,percent of total billed charges,,,8.19,,,percent of total billed charges,,,10.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.67,,,percent of total billed charges,,
DABIGATRAN 75 MG CAPS,2500031809,CDM,637,RC,597035556,NDC,999,EAPG,,,,outpatient,facility,75,UN,10.92,10.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEFLUNOMIDE 10 MG TAB,2500031824,CDM,637,RC,2315504303,NDC,,,,,,inpatient,facility,10,UN,149.69,149.69,11.98,149.69,,,,,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.72,,,percent of total billed charges,,,,,,,,,149.69,,,percent of total billed charges,,,82.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,149.69,,,percent of total billed charges,,,78.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.98,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.11,,,percent of total billed charges,,
LEFLUNOMIDE 10 MG TAB,2500031824,CDM,637,RC,2315504303,NDC,,,,,,outpatient,facility,10,UN,149.69,149.69,11.98,618.77,,87.42,,,percent of total billed charges,,,29.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,149.69,,,percent of total billed charges,,,131.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,131.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,131.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,54.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,134.72,,,percent of total billed charges,,,,,,,,,149.69,,,percent of total billed charges,,,101.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.96,,,percent of total billed charges,,,,,,,,,,,,,,,80.83,,,percent of total billed charges,,,80.83,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.05,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.76,,,percent of total billed charges,,,56.7,,,percent of total billed charges,,,77.52,,,percent of total billed charges,,,,,,,,,,,,,,,29.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,55.39,,,percent of total billed charges,,,55.39,,,percent of total billed charges,,,149.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,149.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.98,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,149.69,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,,,,,,,149.69,,,fee schedule,,,139.24,,,percent of total billed charges,,,,,,,,,,,,,,,139.24,,,percent of total billed charges,,,139.24,,,percent of total billed charges,,,139.24,,,percent of total billed charges,,,112.27,,,percent of total billed charges,,,149.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,149.69,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,105.11,,,percent of total billed charges,,
LEFLUNOMIDE 10 MG TAB,2500031824,CDM,637,RC,2315504303,NDC,999,EAPG,,,,outpatient,facility,10,UN,149.69,149.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACOSAMIDE 50 MG TAB,2500031833,CDM,637,RC,131247760,NDC,,,,,,inpatient,facility,50,UN,42.76,42.76,3.42,42.76,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.48,,,percent of total billed charges,,,,,,,,,42.76,,,percent of total billed charges,,,23.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,22.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.42,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.03,,,percent of total billed charges,,
LACOSAMIDE 50 MG TAB,2500031833,CDM,637,RC,131247760,NDC,,,,,,outpatient,facility,50,UN,42.76,42.76,3.42,618.77,,24.97,,,percent of total billed charges,,,8.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,42.76,,,percent of total billed charges,,,37.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,37.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,37.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,15.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,38.48,,,percent of total billed charges,,,,,,,,,42.76,,,percent of total billed charges,,,28.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.84,,,percent of total billed charges,,,,,,,,,,,,,,,23.09,,,percent of total billed charges,,,23.09,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.3,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.5,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,22.15,,,percent of total billed charges,,,,,,,,,,,,,,,8.55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,15.82,,,percent of total billed charges,,,15.82,,,percent of total billed charges,,,42.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,42.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.42,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,,,,,,,42.76,,,fee schedule,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,39.78,,,percent of total billed charges,,,39.78,,,percent of total billed charges,,,32.07,,,percent of total billed charges,,,42.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,42.76,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,30.03,,,percent of total billed charges,,
LACOSAMIDE 50 MG TAB,2500031833,CDM,637,RC,131247760,NDC,999,EAPG,,,,outpatient,facility,50,UN,42.76,42.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIROLIMUS 0.5 MG ORAL,2500031842,CDM,636,RC,J7520,HCPCS,6846268201,NDC,,,,inpatient,facility,0.5,UN,27.95,27.95,2.24,27.95,,,,,,,,,,,,,,27.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.16,,,percent of total billed charges,,,,,,,,,27.95,,,percent of total billed charges,,,15.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.95,,,percent of total billed charges,,,,,,,,,,,,,,,27.95,,,percent of total billed charges,,,14.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,27.95,,,percent of total billed charges,,,27.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.63,,,percent of total billed charges,,
SIROLIMUS 0.5 MG ORAL,2500031842,CDM,636,RC,J7520,HCPCS,6846268201,NDC,,,,outpatient,facility,0.5,UN,27.95,27.95,1.39,618.77,,16.32,,,percent of total billed charges,,,5.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,27.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,27.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,25.16,,,percent of total billed charges,,,,,,,,,27.95,,,percent of total billed charges,,,18.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,27.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.57,,,percent of total billed charges,,,27.95,,,percent of total billed charges,,,27.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.24,,,percent of total billed charges,,,10.59,,,percent of total billed charges,,,14.48,,,percent of total billed charges,,,,,,,,,,,,,,,5.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,27.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.24,,,percent of total billed charges,,,27.95,,,percent of total billed charges,,,27.95,,,percent of total billed charges,,,,,,,,,,,,,,,27.95,,,percent of total billed charges,,,27.95,,,percent of total billed charges,,,,,,,,,27.95,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.39,,,fee schedule,,,27.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,27.95,,,percent of total billed charges,,,27.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,19.63,,,percent of total billed charges,,
SIROLIMUS 0.5 MG ORAL,2500031842,CDM,636,RC,J7520,HCPCS,6846268201,NDC,495,EAPG,,outpatient,facility,0.5,UN,27.95,27.95,20.56,30.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.14,,,fee schedule,,,20.56,,,fee schedule,,,26.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.56,,,fee schedule,,,20.56,,,fee schedule,,,20.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,20.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESTROGEN CONJ CR 30 GM,2500031849,CDM,637,RC,46087221,NDC,,,,,,inpatient,facility,30,UN,1485.17,1485.17,118.81,1485.17,,,,,,,,,,,,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1336.65,,,percent of total billed charges,,,,,,,,,1485.17,,,percent of total billed charges,,,822.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1355.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,1485.17,,,percent of total billed charges,,,774.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,297.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.81,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1042.89,,,percent of total billed charges,,
ESTROGEN CONJ CR 30 GM,2500031849,CDM,637,RC,46087221,NDC,,,,,,outpatient,facility,30,UN,1485.17,1485.17,118.81,1485.17,,867.34,,,percent of total billed charges,,,289.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1485.17,,,percent of total billed charges,,,1307.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1307.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1307.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,543.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1336.65,,,percent of total billed charges,,,,,,,,,1485.17,,,percent of total billed charges,,,1005.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1140.61,,,percent of total billed charges,,,,,,,,,,,,,,,801.99,,,percent of total billed charges,,,801.99,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,774.37,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1128.73,,,percent of total billed charges,,,562.58,,,percent of total billed charges,,,769.17,,,percent of total billed charges,,,,,,,,,,,,,,,297.03,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,549.51,,,percent of total billed charges,,,549.51,,,percent of total billed charges,,,1485.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1485.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,118.81,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,1485.17,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,,,,,,,1485.17,,,fee schedule,,,1381.51,,,percent of total billed charges,,,,,,,,,,,,,,,1381.51,,,percent of total billed charges,,,1381.51,,,percent of total billed charges,,,1381.51,,,percent of total billed charges,,,1113.88,,,percent of total billed charges,,,1485.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1485.17,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1042.89,,,percent of total billed charges,,
ESTROGEN CONJ CR 30 GM,2500031849,CDM,637,RC,46087221,NDC,999,EAPG,,,,outpatient,facility,30,UN,1485.17,1485.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICIL/CLAV 400MG/5ML UDC,2500031861,CDM,637,RC,6586253450,NDC,,,,,,inpatient,facility,5,UN,11.61,11.61,0.93,11.61,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.45,,,percent of total billed charges,,,,,,,,,11.61,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,6.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,
AMOXICIL/CLAV 400MG/5ML UDC,2500031861,CDM,637,RC,6586253450,NDC,,,,,,outpatient,facility,5,UN,11.61,11.61,0.93,618.77,,6.78,,,percent of total billed charges,,,2.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.61,,,percent of total billed charges,,,10.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,10.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,10.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.45,,,percent of total billed charges,,,,,,,,,11.61,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.92,,,percent of total billed charges,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.05,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.82,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.3,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,11.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.93,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,,,,,,,11.61,,,fee schedule,,,10.8,,,percent of total billed charges,,,,,,,,,,,,,,,10.8,,,percent of total billed charges,,,10.8,,,percent of total billed charges,,,10.8,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,11.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.61,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.15,,,percent of total billed charges,,
AMOXICIL/CLAV 400MG/5ML UDC,2500031861,CDM,637,RC,6586253450,NDC,999,EAPG,,,,outpatient,facility,5,UN,11.61,11.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL 2MCG/BUP 0.0625 100ML,2500031869,CDM,636,RC,J3010,HCPCS,6937452525,NDC,,,,inpatient,facility,100,UN,38.02,38.02,3.04,38.02,,,,,,,,,,,,,,38.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.22,,,percent of total billed charges,,,,,,,,,38.02,,,percent of total billed charges,,,21.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.02,,,percent of total billed charges,,,,,,,,,,,,,,,38.02,,,percent of total billed charges,,,19.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,38.02,,,percent of total billed charges,,,38.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.7,,,percent of total billed charges,,
FENTANYL 2MCG/BUP 0.0625 100ML,2500031869,CDM,636,RC,J3010,HCPCS,6937452525,NDC,,,,outpatient,facility,100,UN,38.02,38.02,0.87,618.77,,22.2,,,percent of total billed charges,,,7.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,38.02,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,38.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,13.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,34.22,,,percent of total billed charges,,,,,,,,,38.02,,,percent of total billed charges,,,25.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,38.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.82,,,percent of total billed charges,,,38.02,,,percent of total billed charges,,,38.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.9,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,19.69,,,percent of total billed charges,,,,,,,,,,,,,,,7.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,38.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,38.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.04,,,percent of total billed charges,,,38.02,,,percent of total billed charges,,,38.02,,,percent of total billed charges,,,,,,,,,,,,,,,38.02,,,percent of total billed charges,,,38.02,,,percent of total billed charges,,,,,,,,,38.02,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.87,,,fee schedule,,,38.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,38.02,,,percent of total billed charges,,,38.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,26.7,,,percent of total billed charges,,
FENTANYL 2MCG/BUP 0.0625 100ML,2500031869,CDM,636,RC,J3010,HCPCS,6937452525,NDC,496,EAPG,,outpatient,facility,100,UN,38.02,38.02,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGIC MOUTHWASH,2500031888,CDM,637,RC,6562805004,NDC,,,,,,inpatient,facility,5,UN,4.5,4.5,0.36,4.5,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.05,,,percent of total billed charges,,,,,,,,,4.5,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,
MAGIC MOUTHWASH,2500031888,CDM,637,RC,6562805004,NDC,,,,,,outpatient,facility,5,UN,4.5,4.5,0.36,618.77,,2.63,,,percent of total billed charges,,,0.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,4.5,,,percent of total billed charges,,,3.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4.05,,,percent of total billed charges,,,,,,,,,4.5,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.42,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.67,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,4.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.36,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,,,,,,,4.5,,,fee schedule,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,3.38,,,percent of total billed charges,,,4.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4.5,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.16,,,percent of total billed charges,,
MAGIC MOUTHWASH,2500031888,CDM,637,RC,6562805004,NDC,999,EAPG,,,,outpatient,facility,5,UN,4.5,4.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SENNA EXTRACT LIQ 5 ML UDC,2500031895,CDM,637,RC,4843321940,NDC,,,,,,inpatient,facility,5,UN,2.97,2.97,0.24,2.97,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.09,,,percent of total billed charges,,
SENNA EXTRACT LIQ 5 ML UDC,2500031895,CDM,637,RC,4843321940,NDC,,,,,,outpatient,facility,5,UN,2.97,2.97,0.24,618.77,,1.73,,,percent of total billed charges,,,0.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.97,,,percent of total billed charges,,,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.67,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,fee schedule,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.09,,,percent of total billed charges,,
SENNA EXTRACT LIQ 5 ML UDC,2500031895,CDM,637,RC,4843321940,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.97,2.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MASTISOL STERILE STRIP,2500031915,CDM,637,RC,496052348,NDC,,,,,,inpatient,facility,0.66,UN,3.52,3.52,0.28,3.52,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,3.52,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,
MASTISOL STERILE STRIP,2500031915,CDM,637,RC,496052348,NDC,,,,,,outpatient,facility,0.66,UN,3.52,3.52,0.28,618.77,,2.06,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.52,,,percent of total billed charges,,,3.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.17,,,percent of total billed charges,,,,,,,,,3.52,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.3,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,3.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,,,,,,,3.52,,,fee schedule,,,3.27,,,percent of total billed charges,,,,,,,,,,,,,,,3.27,,,percent of total billed charges,,,3.27,,,percent of total billed charges,,,3.27,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,3.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.52,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.47,,,percent of total billed charges,,
MASTISOL STERILE STRIP,2500031915,CDM,637,RC,496052348,NDC,999,EAPG,,,,outpatient,facility,0.66,UN,3.52,3.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPRENORPHIN SL FILM 8 MG/2 MG,2500031952,CDM,636,RC,J0574,HCPCS,4778135703,NDC,,,,inpatient,facility,1,UN,29,29,2.32,29,,,,,,,,,,,,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.1,,,percent of total billed charges,,,,,,,,,29,,,percent of total billed charges,,,16.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,29,,,percent of total billed charges,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.36,,,percent of total billed charges,,
BUPRENORPHIN SL FILM 8 MG/2 MG,2500031952,CDM,636,RC,J0574,HCPCS,4778135703,NDC,,,,outpatient,facility,1,UN,29,29,2.32,618.77,,16.94,,,percent of total billed charges,,,5.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,29,,,percent of total billed charges,,,10.45,,,fee schedule,,,10.07,,,fee schedule,,,,,,,,,10.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26.1,,,percent of total billed charges,,,,,,,,,29,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.27,,,percent of total billed charges,,,,,,,,,,,,,,,7.91,,,fee schedule,,,7.91,,,fee schedule,,,,,,,,,618.77,,,per diem,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.12,,,percent of total billed charges,,,29,,,percent of total billed charges,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.04,,,percent of total billed charges,,,10.99,,,percent of total billed charges,,,15.02,,,percent of total billed charges,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.32,,,percent of total billed charges,,,29,,,percent of total billed charges,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,29,,,percent of total billed charges,,,,,,,,,29,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,21.75,,,percent of total billed charges,,,29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,29,,,percent of total billed charges,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.36,,,percent of total billed charges,,
BUPRENORPHIN SL FILM 8 MG/2 MG,2500031952,CDM,636,RC,J0574,HCPCS,4778135703,NDC,435,EAPG,,outpatient,facility,1,UN,29,29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPRENORPH SL FILM 2 MG/0.5 MG,2500031953,CDM,636,RC,J0572,HCPCS,4778135503,NDC,,,,inpatient,facility,1,UN,16.2,16.2,1.3,16.2,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.58,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,8.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.38,,,percent of total billed charges,,
BUPRENORPH SL FILM 2 MG/0.5 MG,2500031953,CDM,636,RC,J0572,HCPCS,4778135503,NDC,,,,outpatient,facility,1,UN,16.2,16.2,1.3,618.77,,9.46,,,percent of total billed charges,,,3.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,16.2,,,percent of total billed charges,,,5.28,,,fee schedule,,,5.09,,,fee schedule,,,,,,,,,5.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,14.58,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,10.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.44,,,percent of total billed charges,,,,,,,,,,,,,,,4,,,fee schedule,,,4,,,fee schedule,,,,,,,,,618.77,,,per diem,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,4.34,,,fee schedule,,,4.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.31,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,8.39,,,percent of total billed charges,,,,,,,,,,,,,,,3.24,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,16.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.3,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,16.2,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,12.15,,,percent of total billed charges,,,16.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.2,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.38,,,percent of total billed charges,,
BUPRENORPH SL FILM 2 MG/0.5 MG,2500031953,CDM,636,RC,J0572,HCPCS,4778135503,NDC,435,EAPG,,outpatient,facility,1,UN,16.2,16.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ABACAVIR/LAMIVUDINE ORAL,2500031954,CDM,637,RC,6818028806,NDC,,,,,,inpatient,facility,1,UN,153.45,153.45,12.28,153.45,,,,,,,,,,,,,,153.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.1,,,percent of total billed charges,,,,,,,,,153.45,,,percent of total billed charges,,,84.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.45,,,percent of total billed charges,,,,,,,,,,,,,,,153.45,,,percent of total billed charges,,,80.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,153.45,,,percent of total billed charges,,,153.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,153.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.75,,,percent of total billed charges,,
ABACAVIR/LAMIVUDINE ORAL,2500031954,CDM,637,RC,6818028806,NDC,,,,,,outpatient,facility,1,UN,153.45,153.45,12.28,618.77,,89.61,,,percent of total billed charges,,,29.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,153.45,,,percent of total billed charges,,,135.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,135.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,135.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,153.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,56.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,138.1,,,percent of total billed charges,,,,,,,,,153.45,,,percent of total billed charges,,,103.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.85,,,percent of total billed charges,,,,,,,,,,,,,,,82.86,,,percent of total billed charges,,,82.86,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,153.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,80.01,,,percent of total billed charges,,,153.45,,,percent of total billed charges,,,153.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.62,,,percent of total billed charges,,,58.13,,,percent of total billed charges,,,79.47,,,percent of total billed charges,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,56.78,,,percent of total billed charges,,,56.78,,,percent of total billed charges,,,153.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,153.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.28,,,percent of total billed charges,,,153.45,,,percent of total billed charges,,,153.45,,,percent of total billed charges,,,,,,,,,,,,,,,153.45,,,percent of total billed charges,,,153.45,,,percent of total billed charges,,,,,,,,,153.45,,,fee schedule,,,142.74,,,percent of total billed charges,,,,,,,,,,,,,,,142.74,,,percent of total billed charges,,,142.74,,,percent of total billed charges,,,142.74,,,percent of total billed charges,,,115.09,,,percent of total billed charges,,,153.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,153.45,,,percent of total billed charges,,,153.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,107.75,,,percent of total billed charges,,
ABACAVIR/LAMIVUDINE ORAL,2500031954,CDM,637,RC,6818028806,NDC,999,EAPG,,,,outpatient,facility,1,UN,153.45,153.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACOSAMIDE 200 MG/20 ML VIAL,2500031955,CDM,636,RC,C9254,HCPCS,131181067,NDC,,,,inpatient,facility,20,UN,319.01,319.01,25.52,319.01,,,,,,,,,,,,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.11,,,percent of total billed charges,,,,,,,,,319.01,,,percent of total billed charges,,,176.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,291.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,319.01,,,percent of total billed charges,,,166.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.52,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.01,,,percent of total billed charges,,
LACOSAMIDE 200 MG/20 ML VIAL,2500031955,CDM,636,RC,C9254,HCPCS,131181067,NDC,,,,outpatient,facility,20,UN,319.01,319.01,25.52,618.77,,186.3,,,percent of total billed charges,,,62.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,319.01,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,116.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,287.11,,,percent of total billed charges,,,,,,,,,319.01,,,percent of total billed charges,,,216.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,166.33,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.45,,,percent of total billed charges,,,120.84,,,percent of total billed charges,,,165.22,,,percent of total billed charges,,,,,,,,,,,,,,,63.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,319.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,319.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.52,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,319.01,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,,,,,,,319.01,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,239.26,,,percent of total billed charges,,,319.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,319.01,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,224.01,,,percent of total billed charges,,
LACOSAMIDE 200 MG/20 ML VIAL,2500031955,CDM,636,RC,C9254,HCPCS,131181067,NDC,999,EAPG,,outpatient,facility,20,UN,319.01,319.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TICAGRELOR 90 MG TAB,2500031965,CDM,637,RC,186077739,NDC,,,,,,inpatient,facility,90,UN,24.81,24.81,1.98,24.81,,,,,,,,,,,,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.33,,,percent of total billed charges,,,,,,,,,24.81,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,24.81,,,percent of total billed charges,,,12.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.42,,,percent of total billed charges,,
TICAGRELOR 90 MG TAB,2500031965,CDM,637,RC,186077739,NDC,,,,,,outpatient,facility,90,UN,24.81,24.81,1.98,618.77,,14.49,,,percent of total billed charges,,,4.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,24.81,,,percent of total billed charges,,,21.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,21.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,21.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22.33,,,percent of total billed charges,,,,,,,,,24.81,,,percent of total billed charges,,,16.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.05,,,percent of total billed charges,,,,,,,,,,,,,,,13.4,,,percent of total billed charges,,,13.4,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.94,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.86,,,percent of total billed charges,,,9.4,,,percent of total billed charges,,,12.85,,,percent of total billed charges,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,9.18,,,percent of total billed charges,,,9.18,,,percent of total billed charges,,,24.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.98,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,24.81,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,,,,,,,24.81,,,fee schedule,,,23.08,,,percent of total billed charges,,,,,,,,,,,,,,,23.08,,,percent of total billed charges,,,23.08,,,percent of total billed charges,,,23.08,,,percent of total billed charges,,,18.61,,,percent of total billed charges,,,24.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,24.81,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.42,,,percent of total billed charges,,
TICAGRELOR 90 MG TAB,2500031965,CDM,637,RC,186077739,NDC,999,EAPG,,,,outpatient,facility,90,UN,24.81,24.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOLUTEGRAVIR 50 MG TAB,2500031981,CDM,250,RC,4970222813,NDC,,,,,,inpatient,facility,50,UN,248.33,248.33,19.87,248.33,,,,,,,,,,,,,,248.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.5,,,percent of total billed charges,,,,,,,,,248.33,,,percent of total billed charges,,,137.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.33,,,percent of total billed charges,,,,,,,,,,,,,,,248.33,,,percent of total billed charges,,,129.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.87,,,percent of total billed charges,,,248.33,,,percent of total billed charges,,,248.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,248.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.38,,,percent of total billed charges,,
DOLUTEGRAVIR 50 MG TAB,2500031981,CDM,250,RC,4970222813,NDC,,,,,,outpatient,facility,50,UN,248.33,248.33,19.87,618.77,,145.02,,,percent of total billed charges,,,48.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,248.33,,,percent of total billed charges,,,218.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,218.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,218.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,248.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,90.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,223.5,,,percent of total billed charges,,,,,,,,,248.33,,,percent of total billed charges,,,168.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,248.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,129.48,,,percent of total billed charges,,,248.33,,,percent of total billed charges,,,248.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.73,,,percent of total billed charges,,,94.07,,,percent of total billed charges,,,128.61,,,percent of total billed charges,,,,,,,,,,,,,,,49.67,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,99.33,,,percent of total billed charges,,,99.33,,,percent of total billed charges,,,248.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,248.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.87,,,percent of total billed charges,,,248.33,,,percent of total billed charges,,,248.33,,,percent of total billed charges,,,,,,,,,,,,,,,248.33,,,percent of total billed charges,,,248.33,,,percent of total billed charges,,,,,,,,,248.33,,,fee schedule,,,99.33,,,percent of total billed charges,,,,,,,,,,,,,,,99.33,,,percent of total billed charges,,,99.33,,,percent of total billed charges,,,99.33,,,percent of total billed charges,,,186.25,,,percent of total billed charges,,,248.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,248.33,,,percent of total billed charges,,,248.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,174.38,,,percent of total billed charges,,
DOLUTEGRAVIR 50 MG TAB,2500031981,CDM,250,RC,4970222813,NDC,999,EAPG,,,,outpatient,facility,50,UN,248.33,248.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TBO-FILGRASTIM 480 MCG INJ,2500031986,CDM,636,RC,J1447,HCPCS,6345991211,NDC,,,,inpatient,facility,0.8,UN,1583.54,1583.54,126.68,1583.54,,,,,,,,,,,,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1425.19,,,percent of total billed charges,,,,,,,,,1583.54,,,percent of total billed charges,,,876.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1444.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,1583.54,,,percent of total billed charges,,,825.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.68,,,percent of total billed charges,,,1583.54,,,percent of total billed charges,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.96,,,percent of total billed charges,,
TBO-FILGRASTIM 480 MCG INJ,2500031986,CDM,636,RC,J1447,HCPCS,6345991211,NDC,,,,outpatient,facility,0.8,UN,1583.54,1583.54,0.27,1583.54,,0.41,,,fee schedule,,,,,,,,,1583.54,,,percent of total billed charges,,,0.47,,,fee schedule,,,0.46,,,fee schedule,,,,,,,,,0.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1425.19,,,percent of total billed charges,,,,,,,,,1583.54,,,percent of total billed charges,,,1072.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1216.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,fee schedule,,,0.44,,,fee schedule,,,,,,,,,618.77,,,per diem,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,825.66,,,percent of total billed charges,,,1583.54,,,percent of total billed charges,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1203.49,,,percent of total billed charges,,,599.84,,,percent of total billed charges,,,820.12,,,percent of total billed charges,,,,,,,,,,,,,,,316.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.86,,,fee schedule,,,0.38,,,fee schedule,,,,,,,,,,,,,,,126.68,,,percent of total billed charges,,,1583.54,,,percent of total billed charges,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,1583.54,,,percent of total billed charges,,,1583.54,,,percent of total billed charges,,,,,,,,,1583.54,,,fee schedule,,,0.41,,,fee schedule,,,,,,,,,,,,,,,0.36,,,fee schedule,,,0.48,,,fee schedule,,,0.27,,,fee schedule,,,0.42,,,fee schedule,,,1583.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1583.54,,,percent of total billed charges,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,791.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1111.96,,,percent of total billed charges,,
TBO-FILGRASTIM 480 MCG INJ,2500031986,CDM,636,RC,J1447,HCPCS,6345991211,NDC,1748,APC,,outpatient,facility,0.8,UN,1583.54,1583.54,0.38,579.58,,,,,,,,0.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,579.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.4,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,0.4,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,,,,,,,,0.58,,,fee schedule,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.38,,,fee schedule,,,0.43,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.4,,,fee schedule,,,0.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,fee schedule,,,0.4,,,fee schedule,,,0.42,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,,,,,,
TBO-FILGRASTIM 480 MCG INJ,2500031986,CDM,636,RC,J1447,HCPCS,6345991211,NDC,438,EAPG,,outpatient,facility,0.8,UN,1583.54,1583.54,323.15,473.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.74,,,fee schedule,,,323.15,,,fee schedule,,,421.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SEVELAMER CARBONATE 800 MG,2500031988,CDM,637,RC,955105027,NDC,,,,,,inpatient,facility,800,UN,5.61,5.61,0.45,5.61,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.05,,,percent of total billed charges,,,,,,,,,5.61,,,percent of total billed charges,,,3.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.94,,,percent of total billed charges,,
SEVELAMER CARBONATE 800 MG,2500031988,CDM,637,RC,955105027,NDC,,,,,,outpatient,facility,800,UN,5.61,5.61,0.45,618.77,,3.28,,,percent of total billed charges,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.61,,,percent of total billed charges,,,4.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,4.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,4.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.05,,,percent of total billed charges,,,,,,,,,5.61,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.31,,,percent of total billed charges,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,5.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.45,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,5.61,,,fee schedule,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,5.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,3.94,,,percent of total billed charges,,
SEVELAMER CARBONATE 800 MG,2500031988,CDM,637,RC,955105027,NDC,999,EAPG,,,,outpatient,facility,800,UN,5.61,5.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LURASIDONE 20MG TAB,2500031989,CDM,637,RC,6340230230,NDC,,,,,,inpatient,facility,20,UN,156.05,156.05,12.48,156.05,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.45,,,percent of total billed charges,,,,,,,,,156.05,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,81.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.48,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.58,,,percent of total billed charges,,
LURASIDONE 20MG TAB,2500031989,CDM,637,RC,6340230230,NDC,,,,,,outpatient,facility,20,UN,156.05,156.05,12.48,618.77,,91.13,,,percent of total billed charges,,,30.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,156.05,,,percent of total billed charges,,,137.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,137.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,137.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,57.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,140.45,,,percent of total billed charges,,,,,,,,,156.05,,,percent of total billed charges,,,105.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.85,,,percent of total billed charges,,,,,,,,,,,,,,,84.27,,,percent of total billed charges,,,84.27,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.36,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.6,,,percent of total billed charges,,,59.11,,,percent of total billed charges,,,80.82,,,percent of total billed charges,,,,,,,,,,,,,,,31.21,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,57.74,,,percent of total billed charges,,,57.74,,,percent of total billed charges,,,156.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,156.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.48,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,,,,,,,156.05,,,fee schedule,,,145.16,,,percent of total billed charges,,,,,,,,,,,,,,,145.16,,,percent of total billed charges,,,145.16,,,percent of total billed charges,,,145.16,,,percent of total billed charges,,,117.04,,,percent of total billed charges,,,156.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,156.05,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,109.58,,,percent of total billed charges,,
LURASIDONE 20MG TAB,2500031989,CDM,637,RC,6340230230,NDC,999,EAPG,,,,outpatient,facility,20,UN,156.05,156.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ORPHENADRINE 60 MG INJ,2500032000,CDM,636,RC,J2360,HCPCS,641618210,NDC,,,,inpatient,facility,2,UN,51.48,51.48,4.12,51.48,,,,,,,,,,,,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.33,,,percent of total billed charges,,,,,,,,,51.48,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,51.48,,,percent of total billed charges,,,26.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,51.48,,,percent of total billed charges,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.15,,,percent of total billed charges,,
ORPHENADRINE 60 MG INJ,2500032000,CDM,636,RC,J2360,HCPCS,641618210,NDC,,,,outpatient,facility,2,UN,51.48,51.48,4.12,618.77,,30.06,,,percent of total billed charges,,,10.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,51.48,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,18.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,46.33,,,percent of total billed charges,,,,,,,,,51.48,,,percent of total billed charges,,,34.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.84,,,percent of total billed charges,,,51.48,,,percent of total billed charges,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.12,,,percent of total billed charges,,,19.5,,,percent of total billed charges,,,26.66,,,percent of total billed charges,,,,,,,,,,,,,,,10.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,51.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.12,,,percent of total billed charges,,,51.48,,,percent of total billed charges,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,51.48,,,percent of total billed charges,,,51.48,,,percent of total billed charges,,,,,,,,,51.48,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,9.44,,,fee schedule,,,51.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,51.48,,,percent of total billed charges,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,36.15,,,percent of total billed charges,,
ORPHENADRINE 60 MG INJ,2500032000,CDM,636,RC,J2360,HCPCS,641618210,NDC,999,EAPG,,outpatient,facility,2,UN,51.48,51.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYCODONE 15 MG TAB,2500032001,CDM,637,RC,6809400561,NDC,,,,,,inpatient,facility,15,UN,2.34,2.34,0.19,2.34,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,2.34,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,
OXYCODONE 15 MG TAB,2500032001,CDM,637,RC,6809400561,NDC,,,,,,outpatient,facility,15,UN,2.34,2.34,0.19,618.77,,1.37,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.34,,,percent of total billed charges,,,2.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.11,,,percent of total billed charges,,,,,,,,,2.34,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.87,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,2.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,2.34,,,fee schedule,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,2.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.64,,,percent of total billed charges,,
OXYCODONE 15 MG TAB,2500032001,CDM,637,RC,6809400561,NDC,999,EAPG,,,,outpatient,facility,15,UN,2.34,2.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OSELTAMIVIR 30 MG/5 ML ORAL,2500032004,CDM,637,RC,4778138426,NDC,,,,,,inpatient,facility,5,UN,45.05,45.05,3.6,45.05,,,,,,,,,,,,,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.55,,,percent of total billed charges,,,,,,,,,45.05,,,percent of total billed charges,,,24.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,45.05,,,percent of total billed charges,,,23.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.6,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.63,,,percent of total billed charges,,
OSELTAMIVIR 30 MG/5 ML ORAL,2500032004,CDM,637,RC,4778138426,NDC,,,,,,outpatient,facility,5,UN,45.05,45.05,3.6,618.77,,26.31,,,percent of total billed charges,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,45.05,,,percent of total billed charges,,,39.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,39.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,39.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,40.55,,,percent of total billed charges,,,,,,,,,45.05,,,percent of total billed charges,,,30.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.6,,,percent of total billed charges,,,,,,,,,,,,,,,24.33,,,percent of total billed charges,,,24.33,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.49,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.24,,,percent of total billed charges,,,17.06,,,percent of total billed charges,,,23.33,,,percent of total billed charges,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,45.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,45.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.6,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,45.05,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,,,,,,,45.05,,,fee schedule,,,41.91,,,percent of total billed charges,,,,,,,,,,,,,,,41.91,,,percent of total billed charges,,,41.91,,,percent of total billed charges,,,41.91,,,percent of total billed charges,,,33.79,,,percent of total billed charges,,,45.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,45.05,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,31.63,,,percent of total billed charges,,
OSELTAMIVIR 30 MG/5 ML ORAL,2500032004,CDM,637,RC,4778138426,NDC,999,EAPG,,,,outpatient,facility,5,UN,45.05,45.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXAMETHASONE 10 MG ORAL,2500032005,CDM,637,RC,J8540,HCPCS,6332350601,NDC,,,,inpatient,facility,1,UN,24.75,24.75,1.98,24.75,,,,,,,,,,,,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.28,,,percent of total billed charges,,,,,,,,,24.75,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,24.75,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.38,,,percent of total billed charges,,
DEXAMETHASONE 10 MG ORAL,2500032005,CDM,637,RC,J8540,HCPCS,6332350601,NDC,,,,outpatient,facility,1,UN,24.75,24.75,0.07,618.77,,0.07,,,fee schedule,,,4.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,24.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22.28,,,percent of total billed charges,,,,,,,,,24.75,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.81,,,percent of total billed charges,,,9.38,,,percent of total billed charges,,,12.82,,,percent of total billed charges,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,24.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.98,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,24.75,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,,,,,,,24.75,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.07,,,fee schedule,,,24.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,24.75,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.38,,,percent of total billed charges,,
DEXAMETHASONE 10 MG ORAL,2500032005,CDM,637,RC,J8540,HCPCS,6332350601,NDC,999,EAPG,,outpatient,facility,1,UN,24.75,24.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PERFLUTREN PROTEIN-A,2500032010,CDM,636,RC,Q9956,HCPCS,407270718,NDC,,,,inpatient,facility,3,UN,463.32,463.32,37.07,463.32,,,,,,,,,,,,,,463.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,416.99,,,percent of total billed charges,,,,,,,,,463.32,,,percent of total billed charges,,,256.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,463.32,,,percent of total billed charges,,,,,,,,,,,,,,,463.32,,,percent of total billed charges,,,241.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,percent of total billed charges,,,463.32,,,percent of total billed charges,,,463.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,463.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.34,,,percent of total billed charges,,
PERFLUTREN PROTEIN-A,2500032010,CDM,636,RC,Q9956,HCPCS,407270718,NDC,,,,outpatient,facility,3,UN,463.32,463.32,37.07,618.77,,270.58,,,percent of total billed charges,,,90.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,463.32,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,463.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,169.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,416.99,,,percent of total billed charges,,,,,,,,,463.32,,,percent of total billed charges,,,313.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,463.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,241.58,,,percent of total billed charges,,,463.32,,,percent of total billed charges,,,463.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.12,,,percent of total billed charges,,,175.51,,,percent of total billed charges,,,239.95,,,percent of total billed charges,,,,,,,,,,,,,,,92.66,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,463.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,463.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,37.07,,,percent of total billed charges,,,463.32,,,percent of total billed charges,,,463.32,,,percent of total billed charges,,,,,,,,,,,,,,,463.32,,,percent of total billed charges,,,463.32,,,percent of total billed charges,,,,,,,,,463.32,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,43.37,,,fee schedule,,,463.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,463.32,,,percent of total billed charges,,,463.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,325.34,,,percent of total billed charges,,
PERFLUTREN PROTEIN-A,2500032010,CDM,636,RC,Q9956,HCPCS,407270718,NDC,999,EAPG,,outpatient,facility,3,UN,463.32,463.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DALBAVANCIN 500MG VL,2500032015,CDM,636,RC,J0875,HCPCS,5797010001,NDC,,,,inpatient,facility,500,UN,5700.12,5700.12,456.01,5700.12,,,,,,,,,,,,,,5700.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5130.11,,,percent of total billed charges,,,,,,,,,5700.12,,,percent of total billed charges,,,3155.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5200.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5700.12,,,percent of total billed charges,,,,,,,,,,,,,,,5700.12,,,percent of total billed charges,,,2972.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1140.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,456.01,,,percent of total billed charges,,,5700.12,,,percent of total billed charges,,,5700.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5700.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4002.62,,,percent of total billed charges,,
DALBAVANCIN 500MG VL,2500032015,CDM,636,RC,J0875,HCPCS,5797010001,NDC,,,,outpatient,facility,500,UN,5700.12,5700.12,10.35,5700.12,,3328.87,,,percent of total billed charges,,,,,,,,,5700.12,,,percent of total billed charges,,,18.66,,,fee schedule,,,17.98,,,fee schedule,,,,,,,,,17.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,5700.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5130.11,,,percent of total billed charges,,,,,,,,,5700.12,,,percent of total billed charges,,,3860.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4377.69,,,percent of total billed charges,,,,,,,,,,,,,,,15.29,,,fee schedule,,,15.29,,,fee schedule,,,,,,,,,618.77,,,per diem,,,5700.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2972.04,,,percent of total billed charges,,,5700.12,,,percent of total billed charges,,,5700.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4332.09,,,percent of total billed charges,,,2159.21,,,percent of total billed charges,,,2952.09,,,percent of total billed charges,,,,,,,,,,,,,,,1140.02,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,33.46,,,fee schedule,,,14.92,,,fee schedule,,,,,,,,,,,,,,,456.01,,,percent of total billed charges,,,5700.12,,,percent of total billed charges,,,5700.12,,,percent of total billed charges,,,,,,,,,,,,,,,5700.12,,,percent of total billed charges,,,5700.12,,,percent of total billed charges,,,,,,,,,5700.12,,,fee schedule,,,15.92,,,fee schedule,,,,,,,,,,,,,,,14,,,fee schedule,,,18.66,,,fee schedule,,,10.35,,,fee schedule,,,16.39,,,fee schedule,,,5700.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5700.12,,,percent of total billed charges,,,5700.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2850.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4002.62,,,percent of total billed charges,,
DALBAVANCIN 500MG VL,2500032015,CDM,636,RC,J0875,HCPCS,5797010001,NDC,1823,APC,,outpatient,facility,500,UN,5700.12,5700.12,14.98,2086.24,,,,,,,,16.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,15.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.76,,,fee schedule,,,,,,,,,2086.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,15.6,,,fee schedule,,,,,,,,,,,,,,,15.6,,,fee schedule,,,16.38,,,fee schedule,,,,,,,,,15.6,,,fee schedule,,,15.6,,,fee schedule,,,16.38,,,fee schedule,,,,,,,,,,,,,,,22.62,,,fee schedule,,,,,,,,,,,,,,,15.6,,,fee schedule,,,,,,,,,,,,,,,14.98,,,fee schedule,,,16.69,,,fee schedule,,,16.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.6,,,fee schedule,,,15.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,16.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,15.6,,,fee schedule,,,15.6,,,fee schedule,,,,,,,,,,,,,,,15.6,,,fee schedule,,,,,,,,,,,,,,,15.6,,,fee schedule,,,16.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.61,,,fee schedule,,,15.6,,,fee schedule,,,16.22,,,fee schedule,,,15.6,,,fee schedule,,,,,,,,,15.6,,,fee schedule,,,,,,,,,15.6,,,fee schedule,,,,,,,,
DALBAVANCIN 500MG VL,2500032015,CDM,636,RC,J0875,HCPCS,5797010001,NDC,462,EAPG,,outpatient,facility,500,UN,5700.12,5700.12,4397.1,6446.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6446.15,,,fee schedule,,,4397.1,,,fee schedule,,,5730.74,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4397.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4397.1,,,fee schedule,,,4397.1,,,fee schedule,,,4397.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4397.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,4397.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICIL/CLAV 250 MG/5 ML,2500032025,CDM,637,RC,5965102601,NDC,,,,,,inpatient,facility,5,UN,14.25,14.25,1.14,14.25,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.83,,,percent of total billed charges,,,,,,,,,14.25,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.01,,,percent of total billed charges,,
AMOXICIL/CLAV 250 MG/5 ML,2500032025,CDM,637,RC,5965102601,NDC,,,,,,outpatient,facility,5,UN,14.25,14.25,1.14,618.77,,8.32,,,percent of total billed charges,,,2.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.25,,,percent of total billed charges,,,12.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.83,,,percent of total billed charges,,,,,,,,,14.25,,,percent of total billed charges,,,9.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.94,,,percent of total billed charges,,,,,,,,,,,,,,,7.7,,,percent of total billed charges,,,7.7,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.83,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,7.38,,,percent of total billed charges,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.27,,,percent of total billed charges,,,5.27,,,percent of total billed charges,,,14.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.14,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,14.25,,,fee schedule,,,13.26,,,percent of total billed charges,,,,,,,,,,,,,,,13.26,,,percent of total billed charges,,,13.26,,,percent of total billed charges,,,13.26,,,percent of total billed charges,,,10.69,,,percent of total billed charges,,,14.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.25,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,10.01,,,percent of total billed charges,,
AMOXICIL/CLAV 250 MG/5 ML,2500032025,CDM,637,RC,5965102601,NDC,999,EAPG,,,,outpatient,facility,5,UN,14.25,14.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AZITHROMYCIN 200 MG/5 ML,2500032026,CDM,637,RC,4280615134,NDC,,,,,,inpatient,facility,5,UN,19.17,19.17,1.53,19.17,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.25,,,percent of total billed charges,,,,,,,,,19.17,,,percent of total billed charges,,,10.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,
AZITHROMYCIN 200 MG/5 ML,2500032026,CDM,637,RC,4280615134,NDC,,,,,,outpatient,facility,5,UN,19.17,19.17,1.53,618.77,,11.2,,,percent of total billed charges,,,3.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,19.17,,,percent of total billed charges,,,16.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,16.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,16.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,17.25,,,percent of total billed charges,,,,,,,,,19.17,,,percent of total billed charges,,,12.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.72,,,percent of total billed charges,,,,,,,,,,,,,,,10.35,,,percent of total billed charges,,,10.35,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.57,,,percent of total billed charges,,,7.26,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.09,,,percent of total billed charges,,,7.09,,,percent of total billed charges,,,19.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.53,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,19.17,,,fee schedule,,,17.83,,,percent of total billed charges,,,,,,,,,,,,,,,17.83,,,percent of total billed charges,,,17.83,,,percent of total billed charges,,,17.83,,,percent of total billed charges,,,14.38,,,percent of total billed charges,,,19.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,19.17,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,13.46,,,percent of total billed charges,,
AZITHROMYCIN 200 MG/5 ML,2500032026,CDM,637,RC,4280615134,NDC,999,EAPG,,,,outpatient,facility,5,UN,19.17,19.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEPHALEXIN 250 MG/5 ML SYR,2500032028,CDM,637,RC,6787754588,NDC,,,,,,inpatient,facility,5,UN,3.76,3.76,0.3,3.76,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,
CEPHALEXIN 250 MG/5 ML SYR,2500032028,CDM,637,RC,6787754588,NDC,,,,,,outpatient,facility,5,UN,3.76,3.76,0.3,618.77,,2.2,,,percent of total billed charges,,,0.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.76,,,percent of total billed charges,,,3.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.38,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,3.76,,,fee schedule,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,2.82,,,percent of total billed charges,,,3.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.64,,,percent of total billed charges,,
CEPHALEXIN 250 MG/5 ML SYR,2500032028,CDM,637,RC,6787754588,NDC,999,EAPG,,,,outpatient,facility,5,UN,3.76,3.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTAZIDIME/AVIBACTAM 2G/0.5G,2500032030,CDM,636,RC,J0714,HCPCS,456270010,NDC,,,,inpatient,facility,2.5,GR,1243.28,1243.28,99.46,1243.28,,,,,,,,,,,,,,1243.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1118.95,,,percent of total billed charges,,,,,,,,,1243.28,,,percent of total billed charges,,,688.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1134.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1243.28,,,percent of total billed charges,,,,,,,,,,,,,,,1243.28,,,percent of total billed charges,,,648.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.46,,,percent of total billed charges,,,1243.28,,,percent of total billed charges,,,1243.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1243.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.03,,,percent of total billed charges,,
CEFTAZIDIME/AVIBACTAM 2G/0.5G,2500032030,CDM,636,RC,J0714,HCPCS,456270010,NDC,,,,outpatient,facility,2.5,GR,1243.28,1243.28,62.54,1243.28,,726.08,,,percent of total billed charges,,,,,,,,,1243.28,,,percent of total billed charges,,,118.44,,,fee schedule,,,114.13,,,fee schedule,,,,,,,,,114.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1243.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1118.95,,,percent of total billed charges,,,,,,,,,1243.28,,,percent of total billed charges,,,841.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,954.84,,,percent of total billed charges,,,,,,,,,,,,,,,95.45,,,fee schedule,,,95.45,,,fee schedule,,,,,,,,,618.77,,,per diem,,,1243.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,648.25,,,percent of total billed charges,,,1243.28,,,percent of total billed charges,,,1243.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,944.89,,,percent of total billed charges,,,470.95,,,percent of total billed charges,,,643.89,,,percent of total billed charges,,,,,,,,,,,,,,,248.66,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,202.25,,,fee schedule,,,90.17,,,fee schedule,,,,,,,,,,,,,,,99.46,,,percent of total billed charges,,,1243.28,,,percent of total billed charges,,,1243.28,,,percent of total billed charges,,,,,,,,,,,,,,,1243.28,,,percent of total billed charges,,,1243.28,,,percent of total billed charges,,,,,,,,,1243.28,,,fee schedule,,,96.22,,,fee schedule,,,,,,,,,,,,,,,84.62,,,fee schedule,,,112.82,,,fee schedule,,,62.54,,,fee schedule,,,103.98,,,fee schedule,,,1243.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1243.28,,,percent of total billed charges,,,1243.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,621.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,873.03,,,percent of total billed charges,,
CEFTAZIDIME/AVIBACTAM 2G/0.5G,2500032030,CDM,636,RC,J0714,HCPCS,456270010,NDC,1825,APC,,outpatient,facility,2.5,GR,1243.28,1243.28,96.7,455.04,,,,,,,,103.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,100.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.74,,,fee schedule,,,,,,,,,455.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,100.73,,,fee schedule,,,,,,,,,,,,,,,100.73,,,fee schedule,,,105.77,,,fee schedule,,,,,,,,,100.73,,,fee schedule,,,100.73,,,fee schedule,,,105.77,,,fee schedule,,,,,,,,,,,,,,,146.06,,,fee schedule,,,,,,,,,,,,,,,100.73,,,fee schedule,,,,,,,,,,,,,,,96.7,,,fee schedule,,,107.78,,,fee schedule,,,105.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.73,,,fee schedule,,,100.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,104.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,125.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,100.73,,,fee schedule,,,100.73,,,fee schedule,,,,,,,,,,,,,,,100.73,,,fee schedule,,,,,,,,,,,,,,,100.73,,,fee schedule,,,103.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.58,,,fee schedule,,,100.73,,,fee schedule,,,104.76,,,fee schedule,,,100.73,,,fee schedule,,,,,,,,,100.73,,,fee schedule,,,,,,,,,100.73,,,fee schedule,,,,,,,,
CEFTAZIDIME/AVIBACTAM 2G/0.5G,2500032030,CDM,636,RC,J0714,HCPCS,456270010,NDC,438,EAPG,,outpatient,facility,2.5,GR,1243.28,1243.28,323.15,473.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.74,,,fee schedule,,,323.15,,,fee schedule,,,421.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROXYZINE 10 MG/5 ML UDC,2500032038,CDM,637,RC,J8499,HCPCS,6043215004,NDC,,,,inpatient,facility,5,UN,2.77,2.77,0.22,2.77,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,
HYDROXYZINE 10 MG/5 ML UDC,2500032038,CDM,637,RC,J8499,HCPCS,6043215004,NDC,,,,outpatient,facility,5,UN,2.77,2.77,0.22,618.77,,1.62,,,percent of total billed charges,,,0.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,2.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.49,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.77,,,fee schedule,,,2.77,,,fee schedule,,,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,2.77,,,fee schedule,,,2.77,,,fee schedule,,,,,,,,,,,,,,,2.77,,,fee schedule,,,2.77,,,fee schedule,,,2.77,,,fee schedule,,,2.08,,,percent of total billed charges,,,2.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.95,,,percent of total billed charges,,
HYDROXYZINE 10 MG/5 ML UDC,2500032038,CDM,637,RC,J8499,HCPCS,6043215004,NDC,435,EAPG,,outpatient,facility,5,UN,2.77,2.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOSTIGMINE 3 MG/3 ML SYR,2500032041,CDM,636,RC,J2710,HCPCS,7604538330,NDC,,,,inpatient,facility,3,ML,49.5,49.5,3.96,49.5,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.55,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,27.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,25.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.76,,,percent of total billed charges,,
NEOSTIGMINE 3 MG/3 ML SYR,2500032041,CDM,636,RC,J2710,HCPCS,7604538330,NDC,,,,outpatient,facility,3,ML,49.5,49.5,0.43,618.77,,28.91,,,percent of total billed charges,,,9.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,49.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,18.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,44.55,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,33.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.81,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.62,,,percent of total billed charges,,,18.75,,,percent of total billed charges,,,25.64,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,49.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,49.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.96,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,49.5,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.43,,,fee schedule,,,49.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,34.76,,,percent of total billed charges,,
NEOSTIGMINE 3 MG/3 ML SYR,2500032041,CDM,636,RC,J2710,HCPCS,7604538330,NDC,999,EAPG,,outpatient,facility,3,ML,49.5,49.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPINEPHRINE INJ 0.1 MG,2500032055,CDM,636,RC,J0171,HCPCS,5428810310,NDC,,,,inpatient,facility,0.1,ML,0.59,0.59,0.05,0.59,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,
EPINEPHRINE INJ 0.1 MG,2500032055,CDM,636,RC,J0171,HCPCS,5428810310,NDC,,,,outpatient,facility,0.1,ML,0.59,0.59,0.05,618.77,,0.34,,,percent of total billed charges,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.53,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,0.59,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,0.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.41,,,percent of total billed charges,,
EPINEPHRINE INJ 0.1 MG,2500032055,CDM,636,RC,J0171,HCPCS,5428810310,NDC,496,EAPG,,outpatient,facility,0.1,ML,0.59,0.59,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SACUBTRL/VALSRTAN 24/26 MG TAB,2500032061,CDM,637,RC,78065920,NDC,,,,,,inpatient,facility,1,UN,37.85,37.85,3.03,37.85,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.07,,,percent of total billed charges,,,,,,,,,37.85,,,percent of total billed charges,,,20.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,19.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.58,,,percent of total billed charges,,
SACUBTRL/VALSRTAN 24/26 MG TAB,2500032061,CDM,637,RC,78065920,NDC,,,,,,outpatient,facility,1,UN,37.85,37.85,3.03,618.77,,22.1,,,percent of total billed charges,,,7.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,37.85,,,percent of total billed charges,,,33.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,33.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,33.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,13.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,34.07,,,percent of total billed charges,,,,,,,,,37.85,,,percent of total billed charges,,,25.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.07,,,percent of total billed charges,,,,,,,,,,,,,,,20.44,,,percent of total billed charges,,,20.44,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.73,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.77,,,percent of total billed charges,,,14.34,,,percent of total billed charges,,,19.6,,,percent of total billed charges,,,,,,,,,,,,,,,7.57,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,14,,,percent of total billed charges,,,14,,,percent of total billed charges,,,37.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,37.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.03,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,,,,,,,37.85,,,fee schedule,,,35.21,,,percent of total billed charges,,,,,,,,,,,,,,,35.21,,,percent of total billed charges,,,35.21,,,percent of total billed charges,,,35.21,,,percent of total billed charges,,,28.39,,,percent of total billed charges,,,37.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,37.85,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,26.58,,,percent of total billed charges,,
SACUBTRL/VALSRTAN 24/26 MG TAB,2500032061,CDM,637,RC,78065920,NDC,999,EAPG,,,,outpatient,facility,1,UN,37.85,37.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IDARUCIZUMAB 2.5 GM/50 ML,2500032065,CDM,636,RC,J3590,HCPCS,597019705,NDC,,,,inpatient,facility,50,UN,8095.16,8095.16,647.61,8095.16,,,,,,,,,,,,,,8095.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7285.64,,,percent of total billed charges,,,,,,,,,8095.16,,,percent of total billed charges,,,4481.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7386.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8095.16,,,percent of total billed charges,,,,,,,,,,,,,,,8095.16,,,percent of total billed charges,,,4220.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1619.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,647.61,,,percent of total billed charges,,,8095.16,,,percent of total billed charges,,,8095.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8095.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5684.42,,,percent of total billed charges,,
IDARUCIZUMAB 2.5 GM/50 ML,2500032065,CDM,636,RC,J3590,HCPCS,597019705,NDC,,,,outpatient,facility,50,UN,8095.16,8095.16,319.69,8095.16,,4727.57,,,percent of total billed charges,,,1578.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8095.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8095.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2962.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7285.64,,,percent of total billed charges,,,,,,,,,8095.16,,,percent of total billed charges,,,5482.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6217.08,,,percent of total billed charges,,,,,,,,,,,,,,,8095.16,,,percent of total billed charges,,,8095.16,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,8095.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4220.82,,,percent of total billed charges,,,8095.16,,,percent of total billed charges,,,8095.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6152.32,,,percent of total billed charges,,,3066.45,,,percent of total billed charges,,,4192.48,,,percent of total billed charges,,,,,,,,,,,,,,,1619.03,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,8095.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8095.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,647.61,,,percent of total billed charges,,,8095.16,,,percent of total billed charges,,,8095.16,,,percent of total billed charges,,,,,,,,,,,,,,,8095.16,,,percent of total billed charges,,,8095.16,,,percent of total billed charges,,,,,,,,,8095.16,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,6071.37,,,percent of total billed charges,,,8095.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8095.16,,,percent of total billed charges,,,8095.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4047.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,5684.42,,,percent of total billed charges,,
IDARUCIZUMAB 2.5 GM/50 ML,2500032065,CDM,636,RC,J3590,HCPCS,597019705,NDC,435,EAPG,,outpatient,facility,50,UN,8095.16,8095.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RITONAVIR 100 MG TABLETS,2500032074,CDM,637,RC,54040713,NDC,,,,,,inpatient,facility,100,UN,30.56,30.56,2.44,30.56,,,,,,,,,,,,,,30.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.5,,,percent of total billed charges,,,,,,,,,30.56,,,percent of total billed charges,,,16.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.56,,,percent of total billed charges,,,,,,,,,,,,,,,30.56,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.44,,,percent of total billed charges,,,30.56,,,percent of total billed charges,,,30.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.46,,,percent of total billed charges,,
RITONAVIR 100 MG TABLETS,2500032074,CDM,637,RC,54040713,NDC,,,,,,outpatient,facility,100,UN,30.56,30.56,2.44,618.77,,17.85,,,percent of total billed charges,,,5.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,30.56,,,percent of total billed charges,,,26.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,26.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,26.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,11.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,27.5,,,percent of total billed charges,,,,,,,,,30.56,,,percent of total billed charges,,,20.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.47,,,percent of total billed charges,,,,,,,,,,,,,,,16.5,,,percent of total billed charges,,,16.5,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,30.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.93,,,percent of total billed charges,,,30.56,,,percent of total billed charges,,,30.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.23,,,percent of total billed charges,,,11.58,,,percent of total billed charges,,,15.83,,,percent of total billed charges,,,,,,,,,,,,,,,6.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,11.31,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,30.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.44,,,percent of total billed charges,,,30.56,,,percent of total billed charges,,,30.56,,,percent of total billed charges,,,,,,,,,,,,,,,30.56,,,percent of total billed charges,,,30.56,,,percent of total billed charges,,,,,,,,,30.56,,,fee schedule,,,28.43,,,percent of total billed charges,,,,,,,,,,,,,,,28.43,,,percent of total billed charges,,,28.43,,,percent of total billed charges,,,28.43,,,percent of total billed charges,,,22.92,,,percent of total billed charges,,,30.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,30.56,,,percent of total billed charges,,,30.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,21.46,,,percent of total billed charges,,
RITONAVIR 100 MG TABLETS,2500032074,CDM,637,RC,54040713,NDC,999,EAPG,,,,outpatient,facility,100,UN,30.56,30.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOBAZAM 10 MG TAB,2500032075,CDM,637,RC,832058011,NDC,,,,,,inpatient,facility,10,UN,60.42,60.42,4.83,60.42,,,,,,,,,,,,,,60.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.38,,,percent of total billed charges,,,,,,,,,60.42,,,percent of total billed charges,,,33.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.42,,,percent of total billed charges,,,,,,,,,,,,,,,60.42,,,percent of total billed charges,,,31.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.83,,,percent of total billed charges,,,60.42,,,percent of total billed charges,,,60.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.43,,,percent of total billed charges,,
CLOBAZAM 10 MG TAB,2500032075,CDM,637,RC,832058011,NDC,,,,,,outpatient,facility,10,UN,60.42,60.42,4.83,618.77,,35.29,,,percent of total billed charges,,,11.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,60.42,,,percent of total billed charges,,,53.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,53.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,53.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,60.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,22.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,54.38,,,percent of total billed charges,,,,,,,,,60.42,,,percent of total billed charges,,,40.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.4,,,percent of total billed charges,,,,,,,,,,,,,,,32.63,,,percent of total billed charges,,,32.63,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,60.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.5,,,percent of total billed charges,,,60.42,,,percent of total billed charges,,,60.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.92,,,percent of total billed charges,,,22.89,,,percent of total billed charges,,,31.29,,,percent of total billed charges,,,,,,,,,,,,,,,12.08,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,22.36,,,percent of total billed charges,,,22.36,,,percent of total billed charges,,,60.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,60.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.83,,,percent of total billed charges,,,60.42,,,percent of total billed charges,,,60.42,,,percent of total billed charges,,,,,,,,,,,,,,,60.42,,,percent of total billed charges,,,60.42,,,percent of total billed charges,,,,,,,,,60.42,,,fee schedule,,,56.2,,,percent of total billed charges,,,,,,,,,,,,,,,56.2,,,percent of total billed charges,,,56.2,,,percent of total billed charges,,,56.2,,,percent of total billed charges,,,45.31,,,percent of total billed charges,,,60.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,60.42,,,percent of total billed charges,,,60.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,42.43,,,percent of total billed charges,,
CLOBAZAM 10 MG TAB,2500032075,CDM,637,RC,832058011,NDC,999,EAPG,,,,outpatient,facility,10,UN,60.42,60.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZOCAINE 20  DENTAL GEL,2500032076,CDM,637,RC,5002443203,NDC,,,,,,inpatient,facility,9,UN,19.17,19.17,1.53,19.17,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.25,,,percent of total billed charges,,,,,,,,,19.17,,,percent of total billed charges,,,10.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,
BENZOCAINE 20  DENTAL GEL,2500032076,CDM,637,RC,5002443203,NDC,,,,,,outpatient,facility,9,UN,19.17,19.17,1.53,618.77,,11.2,,,percent of total billed charges,,,3.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,19.17,,,percent of total billed charges,,,16.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,16.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,16.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,17.25,,,percent of total billed charges,,,,,,,,,19.17,,,percent of total billed charges,,,12.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.72,,,percent of total billed charges,,,,,,,,,,,,,,,10.35,,,percent of total billed charges,,,10.35,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.57,,,percent of total billed charges,,,7.26,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.09,,,percent of total billed charges,,,7.09,,,percent of total billed charges,,,19.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.53,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,19.17,,,fee schedule,,,17.83,,,percent of total billed charges,,,,,,,,,,,,,,,17.83,,,percent of total billed charges,,,17.83,,,percent of total billed charges,,,17.83,,,percent of total billed charges,,,14.38,,,percent of total billed charges,,,19.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,19.17,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,13.46,,,percent of total billed charges,,
BENZOCAINE 20  DENTAL GEL,2500032076,CDM,637,RC,5002443203,NDC,999,EAPG,,,,outpatient,facility,9,UN,19.17,19.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MNTHL SUGR FREE LZNGE 1 LOZ,2500032099,CDM,637,RC,3660219209,NDC,,,,,,inpatient,facility,1,UN,1.94,1.94,0.16,1.94,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,
MNTHL SUGR FREE LZNGE 1 LOZ,2500032099,CDM,637,RC,3660219209,NDC,,,,,,outpatient,facility,1,UN,1.94,1.94,0.16,618.77,,1.13,,,percent of total billed charges,,,0.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.94,,,percent of total billed charges,,,1.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.75,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.72,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,1.94,,,fee schedule,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,1.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.36,,,percent of total billed charges,,
MNTHL SUGR FREE LZNGE 1 LOZ,2500032099,CDM,637,RC,3660219209,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.94,1.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSULIN R U-500 1500 UNIT/3 ML,2500032115,CDM,637,RC,J1815,HCPCS,2882427,NDC,,,,inpatient,facility,3,UN,947.43,947.43,75.79,947.43,,,,,,,,,,,,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,852.69,,,percent of total billed charges,,,,,,,,,947.43,,,percent of total billed charges,,,524.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,864.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,947.43,,,percent of total billed charges,,,493.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.79,,,percent of total billed charges,,,947.43,,,percent of total billed charges,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,665.29,,,percent of total billed charges,,
INSULIN R U-500 1500 UNIT/3 ML,2500032115,CDM,637,RC,J1815,HCPCS,2882427,NDC,,,,outpatient,facility,3,UN,947.43,947.43,0.94,947.43,,553.3,,,percent of total billed charges,,,184.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,947.43,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,346.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,852.69,,,percent of total billed charges,,,,,,,,,947.43,,,percent of total billed charges,,,641.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,493.99,,,percent of total billed charges,,,947.43,,,percent of total billed charges,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.05,,,percent of total billed charges,,,358.89,,,percent of total billed charges,,,490.67,,,percent of total billed charges,,,,,,,,,,,,,,,189.49,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,947.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,947.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,75.79,,,percent of total billed charges,,,947.43,,,percent of total billed charges,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,947.43,,,percent of total billed charges,,,947.43,,,percent of total billed charges,,,,,,,,,947.43,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.94,,,fee schedule,,,947.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,947.43,,,percent of total billed charges,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,665.29,,,percent of total billed charges,,
INSULIN R U-500 1500 UNIT/3 ML,2500032115,CDM,637,RC,J1815,HCPCS,2882427,NDC,496,EAPG,,outpatient,facility,3,UN,947.43,947.43,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EMTRICITAB/RILPIVIRINE/TENOFOV,2500032122,CDM,637,RC,6195821011,NDC,,,,,,inpatient,facility,1,UN,398.54,398.54,31.88,398.54,,,,,,,,,,,,,,398.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.69,,,percent of total billed charges,,,,,,,,,398.54,,,percent of total billed charges,,,220.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.54,,,percent of total billed charges,,,,,,,,,,,,,,,398.54,,,percent of total billed charges,,,207.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.88,,,percent of total billed charges,,,398.54,,,percent of total billed charges,,,398.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,398.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.85,,,percent of total billed charges,,
EMTRICITAB/RILPIVIRINE/TENOFOV,2500032122,CDM,637,RC,6195821011,NDC,,,,,,outpatient,facility,1,UN,398.54,398.54,31.88,618.77,,232.75,,,percent of total billed charges,,,77.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,398.54,,,percent of total billed charges,,,350.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,350.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,350.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,398.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,145.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,358.69,,,percent of total billed charges,,,,,,,,,398.54,,,percent of total billed charges,,,269.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.08,,,percent of total billed charges,,,,,,,,,,,,,,,215.21,,,percent of total billed charges,,,215.21,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,398.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,207.8,,,percent of total billed charges,,,398.54,,,percent of total billed charges,,,398.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.89,,,percent of total billed charges,,,150.97,,,percent of total billed charges,,,206.4,,,percent of total billed charges,,,,,,,,,,,,,,,79.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,147.46,,,percent of total billed charges,,,147.46,,,percent of total billed charges,,,398.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,398.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.88,,,percent of total billed charges,,,398.54,,,percent of total billed charges,,,398.54,,,percent of total billed charges,,,,,,,,,,,,,,,398.54,,,percent of total billed charges,,,398.54,,,percent of total billed charges,,,,,,,,,398.54,,,fee schedule,,,370.72,,,percent of total billed charges,,,,,,,,,,,,,,,370.72,,,percent of total billed charges,,,370.72,,,percent of total billed charges,,,370.72,,,percent of total billed charges,,,298.91,,,percent of total billed charges,,,398.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,398.54,,,percent of total billed charges,,,398.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,279.85,,,percent of total billed charges,,
EMTRICITAB/RILPIVIRINE/TENOFOV,2500032122,CDM,637,RC,6195821011,NDC,999,EAPG,,,,outpatient,facility,1,UN,398.54,398.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINACLOTIDE 145 MCG CAP,2500032143,CDM,637,RC,456120130,NDC,,,,,,inpatient,facility,145,UN,59.5,59.5,4.76,59.5,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.55,,,percent of total billed charges,,,,,,,,,59.5,,,percent of total billed charges,,,32.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,31.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.76,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.78,,,percent of total billed charges,,
LINACLOTIDE 145 MCG CAP,2500032143,CDM,637,RC,456120130,NDC,,,,,,outpatient,facility,145,UN,59.5,59.5,4.76,618.77,,34.75,,,percent of total billed charges,,,11.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,59.5,,,percent of total billed charges,,,52.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,52.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,52.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,21.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,53.55,,,percent of total billed charges,,,,,,,,,59.5,,,percent of total billed charges,,,40.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.7,,,percent of total billed charges,,,,,,,,,,,,,,,32.13,,,percent of total billed charges,,,32.13,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.02,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.22,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,30.82,,,percent of total billed charges,,,,,,,,,,,,,,,11.9,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,22.02,,,percent of total billed charges,,,22.02,,,percent of total billed charges,,,59.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,59.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.76,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,,,,,,,59.5,,,fee schedule,,,55.35,,,percent of total billed charges,,,,,,,,,,,,,,,55.35,,,percent of total billed charges,,,55.35,,,percent of total billed charges,,,55.35,,,percent of total billed charges,,,44.63,,,percent of total billed charges,,,59.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,59.5,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,41.78,,,percent of total billed charges,,
LINACLOTIDE 145 MCG CAP,2500032143,CDM,637,RC,456120130,NDC,999,EAPG,,,,outpatient,facility,145,UN,59.5,59.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHOLECALCFERL 50000UNIT CAPSLE,2500032151,CDM,637,RC,7583402001,NDC,,,,,,inpatient,facility,50000,UN,1.37,1.37,0.11,1.37,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,1.37,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,
CHOLECALCFERL 50000UNIT CAPSLE,2500032151,CDM,637,RC,7583402001,NDC,,,,,,outpatient,facility,50000,UN,1.37,1.37,0.11,618.77,,0.8,,,percent of total billed charges,,,0.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.37,,,percent of total billed charges,,,1.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.23,,,percent of total billed charges,,,,,,,,,1.37,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.51,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,1.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,1.37,,,fee schedule,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,1.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.37,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.96,,,percent of total billed charges,,
CHOLECALCFERL 50000UNIT CAPSLE,2500032151,CDM,637,RC,7583402001,NDC,999,EAPG,,,,outpatient,facility,50000,UN,1.37,1.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICILLIN 400 MG/5 ML,2500032156,CDM,637,RC,93416173,NDC,,,,,,inpatient,facility,5,UN,1.61,1.61,0.13,1.61,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,
AMOXICILLIN 400 MG/5 ML,2500032156,CDM,637,RC,93416173,NDC,,,,,,outpatient,facility,5,UN,1.61,1.61,0.13,618.77,,0.94,,,percent of total billed charges,,,0.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.61,,,percent of total billed charges,,,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.45,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.6,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,1.61,,,fee schedule,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,1.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.13,,,percent of total billed charges,,
AMOXICILLIN 400 MG/5 ML,2500032156,CDM,637,RC,93416173,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.61,1.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TETRACAINE 0.5  OPH 4 ML,2500032162,CDM,637,RC,65074114,NDC,,,,,,inpatient,facility,4,UN,43.63,43.63,3.49,43.63,,,,,,,,,,,,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.27,,,percent of total billed charges,,,,,,,,,43.63,,,percent of total billed charges,,,24.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,43.63,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.64,,,percent of total billed charges,,
TETRACAINE 0.5  OPH 4 ML,2500032162,CDM,637,RC,65074114,NDC,,,,,,outpatient,facility,4,UN,43.63,43.63,3.49,618.77,,25.48,,,percent of total billed charges,,,8.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,43.63,,,percent of total billed charges,,,38.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,38.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,38.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,15.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,39.27,,,percent of total billed charges,,,,,,,,,43.63,,,percent of total billed charges,,,29.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.51,,,percent of total billed charges,,,,,,,,,,,,,,,23.56,,,percent of total billed charges,,,23.56,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.75,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.16,,,percent of total billed charges,,,16.53,,,percent of total billed charges,,,22.6,,,percent of total billed charges,,,,,,,,,,,,,,,8.73,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,16.14,,,percent of total billed charges,,,16.14,,,percent of total billed charges,,,43.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.49,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,43.63,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,,,,,,,43.63,,,fee schedule,,,40.58,,,percent of total billed charges,,,,,,,,,,,,,,,40.58,,,percent of total billed charges,,,40.58,,,percent of total billed charges,,,40.58,,,percent of total billed charges,,,32.72,,,percent of total billed charges,,,43.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,43.63,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,30.64,,,percent of total billed charges,,
TETRACAINE 0.5  OPH 4 ML,2500032162,CDM,637,RC,65074114,NDC,999,EAPG,,,,outpatient,facility,4,UN,43.63,43.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARGATROBAN 250MG INJ NON-ESRD,2500032165,CDM,636,RC,J0883,HCPCS,4202318201,NDC,,,,inpatient,facility,2.5,GR,1683,1683,134.64,1683,,,,,,,,,,,,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1514.7,,,percent of total billed charges,,,,,,,,,1683,,,percent of total billed charges,,,931.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1535.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,1683,,,percent of total billed charges,,,877.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.64,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1181.8,,,percent of total billed charges,,
ARGATROBAN 250MG INJ NON-ESRD,2500032165,CDM,636,RC,J0883,HCPCS,4202318201,NDC,,,,outpatient,facility,2.5,GR,1683,1683,0.9,1683,,982.87,,,percent of total billed charges,,,,,,,,,1683,,,percent of total billed charges,,,4.72,,,fee schedule,,,4.54,,,fee schedule,,,,,,,,,4.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1514.7,,,percent of total billed charges,,,,,,,,,1683,,,percent of total billed charges,,,1139.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1292.54,,,percent of total billed charges,,,,,,,,,,,,,,,3.57,,,fee schedule,,,3.57,,,fee schedule,,,,,,,,,618.77,,,per diem,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,877.52,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.08,,,percent of total billed charges,,,637.52,,,percent of total billed charges,,,871.63,,,percent of total billed charges,,,,,,,,,,,,,,,336.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.91,,,fee schedule,,,1.3,,,fee schedule,,,,,,,,,,,,,,,134.64,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,1683,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,,,,,,,1683,,,fee schedule,,,1.39,,,fee schedule,,,,,,,,,,,,,,,1.22,,,fee schedule,,,1.63,,,fee schedule,,,0.9,,,fee schedule,,,1262.25,,,percent of total billed charges,,,1683,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1683,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,841.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1181.8,,,percent of total billed charges,,
ARGATROBAN 250MG INJ NON-ESRD,2500032165,CDM,636,RC,J0883,HCPCS,4202318201,NDC,1859,APC,,outpatient,facility,2.5,GR,1683,1683,0.77,615.98,,,,,,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,fee schedule,,,,,,,,,615.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.8,,,fee schedule,,,,,,,,,,,,,,,0.8,,,fee schedule,,,0.84,,,fee schedule,,,,,,,,,0.8,,,fee schedule,,,0.8,,,fee schedule,,,0.84,,,fee schedule,,,,,,,,,,,,,,,1.16,,,fee schedule,,,,,,,,,,,,,,,0.8,,,fee schedule,,,,,,,,,,,,,,,0.77,,,fee schedule,,,0.86,,,fee schedule,,,0.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,fee schedule,,,0.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.8,,,fee schedule,,,0.8,,,fee schedule,,,,,,,,,,,,,,,0.8,,,fee schedule,,,,,,,,,,,,,,,0.8,,,fee schedule,,,0.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.26,,,fee schedule,,,0.8,,,fee schedule,,,0.83,,,fee schedule,,,0.8,,,fee schedule,,,,,,,,,0.8,,,fee schedule,,,,,,,,,0.8,,,fee schedule,,,,,,,,
ARGATROBAN 250MG INJ NON-ESRD,2500032165,CDM,636,RC,J0883,HCPCS,4202318201,NDC,436,EAPG,,outpatient,facility,2.5,GR,1683,1683,126.95,186.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.11,,,fee schedule,,,126.95,,,fee schedule,,,165.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TBO-FILGRASTIM 300 MCG INJ,2500032170,CDM,636,RC,J1447,HCPCS,6345991859,NDC,,,,inpatient,facility,1,UN,989.44,989.44,79.16,989.44,,,,,,,,,,,,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,890.5,,,percent of total billed charges,,,,,,,,,989.44,,,percent of total billed charges,,,547.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,902.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,989.44,,,percent of total billed charges,,,515.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.16,,,percent of total billed charges,,,989.44,,,percent of total billed charges,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,694.78,,,percent of total billed charges,,
TBO-FILGRASTIM 300 MCG INJ,2500032170,CDM,636,RC,J1447,HCPCS,6345991859,NDC,,,,outpatient,facility,1,UN,989.44,989.44,0.27,989.44,,0.41,,,fee schedule,,,,,,,,,989.44,,,percent of total billed charges,,,0.47,,,fee schedule,,,0.46,,,fee schedule,,,,,,,,,0.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,890.5,,,percent of total billed charges,,,,,,,,,989.44,,,percent of total billed charges,,,670.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,759.89,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,fee schedule,,,0.44,,,fee schedule,,,,,,,,,618.77,,,per diem,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,515.89,,,percent of total billed charges,,,989.44,,,percent of total billed charges,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,751.97,,,percent of total billed charges,,,374.8,,,percent of total billed charges,,,512.43,,,percent of total billed charges,,,,,,,,,,,,,,,197.89,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.86,,,fee schedule,,,0.38,,,fee schedule,,,,,,,,,,,,,,,79.16,,,percent of total billed charges,,,989.44,,,percent of total billed charges,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,989.44,,,percent of total billed charges,,,989.44,,,percent of total billed charges,,,,,,,,,989.44,,,fee schedule,,,0.41,,,fee schedule,,,,,,,,,,,,,,,0.36,,,fee schedule,,,0.48,,,fee schedule,,,0.27,,,fee schedule,,,0.42,,,fee schedule,,,989.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,989.44,,,percent of total billed charges,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,494.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,694.78,,,percent of total billed charges,,
TBO-FILGRASTIM 300 MCG INJ,2500032170,CDM,636,RC,J1447,HCPCS,6345991859,NDC,1748,APC,,outpatient,facility,1,UN,989.44,989.44,0.38,362.14,,,,,,,,0.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,362.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.4,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,0.4,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,,,,,,,,0.58,,,fee schedule,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.38,,,fee schedule,,,0.43,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.4,,,fee schedule,,,0.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,fee schedule,,,0.4,,,fee schedule,,,0.42,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,,,,,,
TBO-FILGRASTIM 300 MCG INJ,2500032170,CDM,636,RC,J1447,HCPCS,6345991859,NDC,438,EAPG,,outpatient,facility,1,UN,989.44,989.44,323.15,473.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.74,,,fee schedule,,,323.15,,,fee schedule,,,421.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLENE BLUE 0.5  10 ML INJ,2500032173,CDM,636,RC,Q9968,HCPCS,517037405,NDC,,,,inpatient,facility,10,UN,773.49,773.49,61.88,773.49,,,,,,,,,,,,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.14,,,percent of total billed charges,,,,,,,,,773.49,,,percent of total billed charges,,,428.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,773.49,,,percent of total billed charges,,,403.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.88,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,543.14,,,percent of total billed charges,,
METHYLENE BLUE 0.5  10 ML INJ,2500032173,CDM,636,RC,Q9968,HCPCS,517037405,NDC,,,,outpatient,facility,10,UN,773.49,773.49,5.51,773.49,,451.72,,,percent of total billed charges,,,,,,,,,773.49,,,percent of total billed charges,,,12.59,,,fee schedule,,,12.13,,,fee schedule,,,,,,,,,12.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,696.14,,,percent of total billed charges,,,,,,,,,773.49,,,percent of total billed charges,,,523.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,594.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.96,,,fee schedule,,,17.96,,,fee schedule,,,,,,,,,618.77,,,per diem,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,403.3,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,587.85,,,percent of total billed charges,,,293,,,percent of total billed charges,,,400.59,,,percent of total billed charges,,,,,,,,,,,,,,,154.7,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,17.83,,,fee schedule,,,7.95,,,fee schedule,,,,,,,,,,,,,,,61.88,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,773.49,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,,,,,,,773.49,,,fee schedule,,,8.48,,,fee schedule,,,,,,,,,,,,,,,7.46,,,fee schedule,,,9.95,,,fee schedule,,,5.51,,,fee schedule,,,580.12,,,percent of total billed charges,,,773.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,773.49,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,543.14,,,percent of total billed charges,,
METHYLENE BLUE 0.5  10 ML INJ,2500032173,CDM,636,RC,Q9968,HCPCS,517037405,NDC,1446,APC,,outpatient,facility,10,UN,773.49,773.49,8.53,283.1,,,,,,,,9.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,8.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.99,,,fee schedule,,,,,,,,,283.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,8.9,,,fee schedule,,,,,,,,,,,,,,,8.9,,,fee schedule,,,9.34,,,fee schedule,,,,,,,,,8.9,,,fee schedule,,,8.9,,,fee schedule,,,9.34,,,fee schedule,,,,,,,,,,,,,,,12.9,,,fee schedule,,,,,,,,,,,,,,,8.9,,,fee schedule,,,,,,,,,,,,,,,8.54,,,fee schedule,,,9.52,,,fee schedule,,,9.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.9,,,fee schedule,,,8.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,9.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,8.9,,,fee schedule,,,8.9,,,fee schedule,,,,,,,,,,,,,,,8.9,,,fee schedule,,,,,,,,,,,,,,,8.9,,,fee schedule,,,9.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.53,,,fee schedule,,,8.9,,,fee schedule,,,9.26,,,fee schedule,,,8.9,,,fee schedule,,,,,,,,,8.9,,,fee schedule,,,,,,,,,8.9,,,fee schedule,,,,,,,,
METHYLENE BLUE 0.5  10 ML INJ,2500032173,CDM,636,RC,Q9968,HCPCS,517037405,NDC,999,EAPG,,outpatient,facility,10,UN,773.49,773.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIDAZOLAM HCL 5MG/5ML VIAL,2500032212,CDM,636,RC,J2250,HCPCS,409230505,NDC,,,,inpatient,facility,5,ML,3.76,3.76,0.3,3.76,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,
MIDAZOLAM HCL 5MG/5ML VIAL,2500032212,CDM,636,RC,J2250,HCPCS,409230505,NDC,,,,outpatient,facility,5,ML,3.76,3.76,0.14,618.77,,2.2,,,percent of total billed charges,,,0.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.76,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.38,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,3.76,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.14,,,fee schedule,,,3.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.64,,,percent of total billed charges,,
MIDAZOLAM HCL 5MG/5ML VIAL,2500032212,CDM,636,RC,J2250,HCPCS,409230505,NDC,496,EAPG,,outpatient,facility,5,ML,3.76,3.76,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF PSY 4MG INJ,2500032213,CDM,636,RC,J2270,HCPCS,409189101,NDC,,,,inpatient,facility,1,ML,6.43,6.43,0.51,6.43,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.79,,,percent of total billed charges,,,,,,,,,6.43,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,,3.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.52,,,percent of total billed charges,,
MORPHINE SULF PSY 4MG INJ,2500032213,CDM,636,RC,J2270,HCPCS,409189101,NDC,,,,outpatient,facility,1,ML,6.43,6.43,0.51,618.77,,3.76,,,percent of total billed charges,,,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.43,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.79,,,percent of total billed charges,,,,,,,,,6.43,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.35,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,6.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.51,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,6.43,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.37,,,fee schedule,,,6.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.43,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.52,,,percent of total billed charges,,
MORPHINE SULF PSY 4MG INJ,2500032213,CDM,636,RC,J2270,HCPCS,409189101,NDC,496,EAPG,,outpatient,facility,1,ML,6.43,6.43,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NALOXONE 2MG/2ML PREFIL SYRNG,2500032214,CDM,636,RC,J2310,HCPCS,7632933691,NDC,,,,inpatient,facility,2,ML,108.9,108.9,8.71,108.9,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.01,,,percent of total billed charges,,,,,,,,,108.9,,,percent of total billed charges,,,60.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,56.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.47,,,percent of total billed charges,,
NALOXONE 2MG/2ML PREFIL SYRNG,2500032214,CDM,636,RC,J2310,HCPCS,7632933691,NDC,,,,outpatient,facility,2,ML,108.9,108.9,8.71,618.77,,63.6,,,percent of total billed charges,,,21.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,108.9,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,39.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,98.01,,,percent of total billed charges,,,,,,,,,108.9,,,percent of total billed charges,,,73.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.78,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.76,,,percent of total billed charges,,,41.25,,,percent of total billed charges,,,56.4,,,percent of total billed charges,,,,,,,,,,,,,,,21.78,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,108.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,108.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.71,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,,,,,,,108.9,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,9.69,,,fee schedule,,,108.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,108.9,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,76.47,,,percent of total billed charges,,
NALOXONE 2MG/2ML PREFIL SYRNG,2500032214,CDM,636,RC,J2310,HCPCS,7632933691,NDC,435,EAPG,,outpatient,facility,2,ML,108.9,108.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDO 1 /EPI 1 100000 10 ML VL,2500032269,CDM,636,RC,J2004,HCPCS,6332348217,NDC,,,,inpatient,facility,10,UN,11.45,11.45,0.92,11.45,,,,,,,,,,,,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.3,,,percent of total billed charges,,,,,,,,,11.45,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,11.45,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.04,,,percent of total billed charges,,
LIDO 1 /EPI 1 100000 10 ML VL,2500032269,CDM,636,RC,J2004,HCPCS,6332348217,NDC,,,,outpatient,facility,10,UN,11.45,11.45,0.92,618.77,,6.69,,,percent of total billed charges,,,2.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.45,,,percent of total billed charges,,,10.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,10.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,10.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.3,,,percent of total billed charges,,,,,,,,,11.45,,,percent of total billed charges,,,7.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.79,,,percent of total billed charges,,,,,,,,,,,,,,,6.18,,,percent of total billed charges,,,6.18,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.7,,,percent of total billed charges,,,4.34,,,percent of total billed charges,,,5.93,,,percent of total billed charges,,,,,,,,,,,,,,,2.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.24,,,percent of total billed charges,,,4.24,,,percent of total billed charges,,,11.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,11.45,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,,,,,,,11.45,,,fee schedule,,,10.65,,,percent of total billed charges,,,,,,,,,,,,,,,10.65,,,percent of total billed charges,,,10.65,,,percent of total billed charges,,,10.65,,,percent of total billed charges,,,8.59,,,percent of total billed charges,,,11.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.45,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.04,,,percent of total billed charges,,
LIDO 1 /EPI 1 100000 10 ML VL,2500032269,CDM,636,RC,J2004,HCPCS,6332348217,NDC,999,EAPG,,outpatient,facility,10,UN,11.45,11.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTOLOZANE/TAZOBACTAM 1G/0.5G,2500032319,CDM,636,RC,J0695,HCPCS,6791903001,NDC,,,,inpatient,facility,1.5,GR,523.54,523.54,41.88,523.54,,,,,,,,,,,,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.19,,,percent of total billed charges,,,,,,,,,523.54,,,percent of total billed charges,,,289.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,477.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,523.54,,,percent of total billed charges,,,272.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.88,,,percent of total billed charges,,,523.54,,,percent of total billed charges,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,367.63,,,percent of total billed charges,,
CEFTOLOZANE/TAZOBACTAM 1G/0.5G,2500032319,CDM,636,RC,J0695,HCPCS,6791903001,NDC,,,,outpatient,facility,1.5,GR,523.54,523.54,4.34,618.77,,305.75,,,percent of total billed charges,,,,,,,,,523.54,,,percent of total billed charges,,,9.74,,,fee schedule,,,9.39,,,fee schedule,,,,,,,,,9.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,471.19,,,percent of total billed charges,,,,,,,,,523.54,,,percent of total billed charges,,,354.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,percent of total billed charges,,,,,,,,,,,,,,,7.37,,,fee schedule,,,7.37,,,fee schedule,,,,,,,,,618.77,,,per diem,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,272.97,,,percent of total billed charges,,,523.54,,,percent of total billed charges,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.89,,,percent of total billed charges,,,198.32,,,percent of total billed charges,,,271.14,,,percent of total billed charges,,,,,,,,,,,,,,,104.71,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,14.01,,,fee schedule,,,6.25,,,fee schedule,,,,,,,,,,,,,,,41.88,,,percent of total billed charges,,,523.54,,,percent of total billed charges,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,523.54,,,percent of total billed charges,,,523.54,,,percent of total billed charges,,,,,,,,,523.54,,,fee schedule,,,6.67,,,fee schedule,,,,,,,,,,,,,,,5.87,,,fee schedule,,,7.82,,,fee schedule,,,4.34,,,fee schedule,,,8.55,,,fee schedule,,,523.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,523.54,,,percent of total billed charges,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,367.63,,,percent of total billed charges,,
CEFTOLOZANE/TAZOBACTAM 1G/0.5G,2500032319,CDM,636,RC,J0695,HCPCS,6791903001,NDC,9452,APC,,outpatient,facility,1.5,GR,523.54,523.54,7.82,191.62,,,,,,,,8.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,8.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.23,,,fee schedule,,,,,,,,,191.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,8.15,,,fee schedule,,,,,,,,,,,,,,,8.15,,,fee schedule,,,8.56,,,fee schedule,,,,,,,,,8.15,,,fee schedule,,,8.15,,,fee schedule,,,8.56,,,fee schedule,,,,,,,,,,,,,,,11.82,,,fee schedule,,,,,,,,,,,,,,,8.15,,,fee schedule,,,,,,,,,,,,,,,7.82,,,fee schedule,,,8.72,,,fee schedule,,,8.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,fee schedule,,,8.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,8.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,8.15,,,fee schedule,,,8.15,,,fee schedule,,,,,,,,,,,,,,,8.15,,,fee schedule,,,,,,,,,,,,,,,8.15,,,fee schedule,,,8.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.23,,,fee schedule,,,8.15,,,fee schedule,,,8.48,,,fee schedule,,,8.15,,,fee schedule,,,,,,,,,8.15,,,fee schedule,,,,,,,,,8.15,,,fee schedule,,,,,,,,
CEFTOLOZANE/TAZOBACTAM 1G/0.5G,2500032319,CDM,636,RC,J0695,HCPCS,6791903001,NDC,437,EAPG,,outpatient,facility,1.5,GR,523.54,523.54,151.7,222.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.39,,,fee schedule,,,151.7,,,fee schedule,,,197.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,151.7,,,fee schedule,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,151.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMINO ACIDS 5  D15 2000ML LYTE,2500032323,CDM,258,RC,338112304,NDC,,,,,,inpatient,facility,2000,UN,282.68,282.68,22.61,282.68,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.41,,,percent of total billed charges,,,,,,,,,282.68,,,percent of total billed charges,,,156.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,147.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.61,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.5,,,percent of total billed charges,,
AMINO ACIDS 5  D15 2000ML LYTE,2500032323,CDM,258,RC,338112304,NDC,,,,,,outpatient,facility,2000,UN,282.68,282.68,22.61,618.77,,165.09,,,percent of total billed charges,,,55.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,282.68,,,percent of total billed charges,,,248.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,248.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,248.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,103.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,254.41,,,percent of total billed charges,,,,,,,,,282.68,,,percent of total billed charges,,,191.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,147.39,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.84,,,percent of total billed charges,,,107.08,,,percent of total billed charges,,,146.4,,,percent of total billed charges,,,,,,,,,,,,,,,56.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,113.07,,,percent of total billed charges,,,113.07,,,percent of total billed charges,,,282.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,282.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.61,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,282.68,,,fee schedule,,,113.07,,,percent of total billed charges,,,,,,,,,,,,,,,113.07,,,percent of total billed charges,,,113.07,,,percent of total billed charges,,,113.07,,,percent of total billed charges,,,212.01,,,percent of total billed charges,,,282.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,198.5,,,percent of total billed charges,,
AMINO ACIDS 5  D15 2000ML LYTE,2500032323,CDM,258,RC,338112304,NDC,999,EAPG,,,,outpatient,facility,2000,UN,282.68,282.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCOPOLAMINE 1 MG PATCH,2500032329,CDM,637,RC,5074250524,NDC,,,,,,inpatient,facility,1,UN,75.8,75.8,6.06,75.8,,,,,,,,,,,,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.22,,,percent of total billed charges,,,,,,,,,75.8,,,percent of total billed charges,,,41.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,75.8,,,percent of total billed charges,,,39.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.06,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.23,,,percent of total billed charges,,
SCOPOLAMINE 1 MG PATCH,2500032329,CDM,637,RC,5074250524,NDC,,,,,,outpatient,facility,1,UN,75.8,75.8,6.06,618.77,,44.27,,,percent of total billed charges,,,14.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,75.8,,,percent of total billed charges,,,66.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,66.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,66.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,27.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,68.22,,,percent of total billed charges,,,,,,,,,75.8,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.21,,,percent of total billed charges,,,,,,,,,,,,,,,40.93,,,percent of total billed charges,,,40.93,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.52,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.61,,,percent of total billed charges,,,28.71,,,percent of total billed charges,,,39.26,,,percent of total billed charges,,,,,,,,,,,,,,,15.16,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,75.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,75.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.06,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,75.8,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,,,,,,,75.8,,,fee schedule,,,70.51,,,percent of total billed charges,,,,,,,,,,,,,,,70.51,,,percent of total billed charges,,,70.51,,,percent of total billed charges,,,70.51,,,percent of total billed charges,,,56.85,,,percent of total billed charges,,,75.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,75.8,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,53.23,,,percent of total billed charges,,
SCOPOLAMINE 1 MG PATCH,2500032329,CDM,637,RC,5074250524,NDC,999,EAPG,,,,outpatient,facility,1,UN,75.8,75.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZOCAINE 20  GEL SWAB,2500032339,CDM,637,RC,5416292629,NDC,,,,,,inpatient,facility,1,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
BENZOCAINE 20  GEL SWAB,2500032339,CDM,637,RC,5416292629,NDC,,,,,,outpatient,facility,1,UN,2,2,0.16,618.77,,1.17,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.8,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2,,,fee schedule,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.4,,,percent of total billed charges,,
BENZOCAINE 20  GEL SWAB,2500032339,CDM,637,RC,5416292629,NDC,999,EAPG,,,,outpatient,facility,1,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFDINIR SUSP 125 MG/5 ML UDL,2500032342,CDM,637,RC,6818072204,NDC,,,,,,inpatient,facility,5,UN,14.02,14.02,1.12,14.02,,,,,,,,,,,,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.62,,,percent of total billed charges,,,,,,,,,14.02,,,percent of total billed charges,,,7.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,14.02,,,percent of total billed charges,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,14.02,,,percent of total billed charges,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.84,,,percent of total billed charges,,
CEFDINIR SUSP 125 MG/5 ML UDL,2500032342,CDM,637,RC,6818072204,NDC,,,,,,outpatient,facility,5,UN,14.02,14.02,1.12,618.77,,8.19,,,percent of total billed charges,,,2.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,14.02,,,percent of total billed charges,,,12.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.62,,,percent of total billed charges,,,,,,,,,14.02,,,percent of total billed charges,,,9.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.77,,,percent of total billed charges,,,,,,,,,,,,,,,7.57,,,percent of total billed charges,,,7.57,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.31,,,percent of total billed charges,,,14.02,,,percent of total billed charges,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.66,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,7.26,,,percent of total billed charges,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.19,,,percent of total billed charges,,,5.19,,,percent of total billed charges,,,14.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.12,,,percent of total billed charges,,,14.02,,,percent of total billed charges,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,14.02,,,percent of total billed charges,,,14.02,,,percent of total billed charges,,,,,,,,,14.02,,,fee schedule,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,10.52,,,percent of total billed charges,,,14.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,14.02,,,percent of total billed charges,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.84,,,percent of total billed charges,,
CEFDINIR SUSP 125 MG/5 ML UDL,2500032342,CDM,637,RC,6818072204,NDC,999,EAPG,,,,outpatient,facility,5,UN,14.02,14.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFDINIR SUSP 250 MG/5 ML UDL,2500032343,CDM,637,RC,6818072304,NDC,,,,,,inpatient,facility,5,UN,27.35,27.35,2.19,27.35,,,,,,,,,,,,,,27.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.62,,,percent of total billed charges,,,,,,,,,27.35,,,percent of total billed charges,,,15.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.35,,,percent of total billed charges,,,,,,,,,,,,,,,27.35,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,27.35,,,percent of total billed charges,,,27.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.21,,,percent of total billed charges,,
CEFDINIR SUSP 250 MG/5 ML UDL,2500032343,CDM,637,RC,6818072304,NDC,,,,,,outpatient,facility,5,UN,27.35,27.35,2.19,618.77,,15.97,,,percent of total billed charges,,,5.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,27.35,,,percent of total billed charges,,,24.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,24.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,24.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,27.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,24.62,,,percent of total billed charges,,,,,,,,,27.35,,,percent of total billed charges,,,18.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21,,,percent of total billed charges,,,,,,,,,,,,,,,14.77,,,percent of total billed charges,,,14.77,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,27.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,27.35,,,percent of total billed charges,,,27.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,14.16,,,percent of total billed charges,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.12,,,percent of total billed charges,,,10.12,,,percent of total billed charges,,,27.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.19,,,percent of total billed charges,,,27.35,,,percent of total billed charges,,,27.35,,,percent of total billed charges,,,,,,,,,,,,,,,27.35,,,percent of total billed charges,,,27.35,,,percent of total billed charges,,,,,,,,,27.35,,,fee schedule,,,25.44,,,percent of total billed charges,,,,,,,,,,,,,,,25.44,,,percent of total billed charges,,,25.44,,,percent of total billed charges,,,25.44,,,percent of total billed charges,,,20.51,,,percent of total billed charges,,,27.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,27.35,,,percent of total billed charges,,,27.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,19.21,,,percent of total billed charges,,
CEFDINIR SUSP 250 MG/5 ML UDL,2500032343,CDM,637,RC,6818072304,NDC,999,EAPG,,,,outpatient,facility,5,UN,27.35,27.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLINDAMYCIN SUSP 15 MG/ML UDL,2500032346,CDM,637,RC,5976200161,NDC,,,,,,inpatient,facility,1,UN,1.35,1.35,0.11,1.35,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,
CLINDAMYCIN SUSP 15 MG/ML UDL,2500032346,CDM,637,RC,5976200161,NDC,,,,,,outpatient,facility,1,UN,1.35,1.35,0.11,618.77,,0.79,,,percent of total billed charges,,,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.35,,,percent of total billed charges,,,1.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.22,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,1.35,,,fee schedule,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.95,,,percent of total billed charges,,
CLINDAMYCIN SUSP 15 MG/ML UDL,2500032346,CDM,637,RC,5976200161,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.35,1.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM/NS 125 MG/125 ML BAG,2500032353,CDM,250,RC,J3490,HCPCS,7219660551,NDC,,,,inpatient,facility,125,UN,53.03,53.03,4.24,53.03,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.73,,,percent of total billed charges,,,,,,,,,53.03,,,percent of total billed charges,,,29.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,27.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.24,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.24,,,percent of total billed charges,,
DILTIAZEM/NS 125 MG/125 ML BAG,2500032353,CDM,250,RC,J3490,HCPCS,7219660551,NDC,,,,outpatient,facility,125,UN,53.03,53.03,1.2,618.77,,30.97,,,percent of total billed charges,,,10.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,53.03,,,percent of total billed charges,,,46.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,46.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,46.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,19.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,47.73,,,percent of total billed charges,,,,,,,,,53.03,,,percent of total billed charges,,,35.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.73,,,percent of total billed charges,,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.65,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.3,,,percent of total billed charges,,,20.09,,,percent of total billed charges,,,27.46,,,percent of total billed charges,,,,,,,,,,,,,,,10.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,53.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.24,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,,,,,,,53.03,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,39.77,,,percent of total billed charges,,,53.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,53.03,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,37.24,,,percent of total billed charges,,
DILTIAZEM/NS 125 MG/125 ML BAG,2500032353,CDM,250,RC,J3490,HCPCS,7219660551,NDC,435,EAPG,,outpatient,facility,125,UN,53.03,53.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EMTRICITABINE/TENOFOV/ALAFENAM,2500032357,CDM,637,RC,6195820021,NDC,,,,,,inpatient,facility,1,UN,242.25,242.25,19.38,242.25,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.03,,,percent of total billed charges,,,,,,,,,242.25,,,percent of total billed charges,,,134.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,126.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.38,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.11,,,percent of total billed charges,,
EMTRICITABINE/TENOFOV/ALAFENAM,2500032357,CDM,637,RC,6195820021,NDC,,,,,,outpatient,facility,1,UN,242.25,242.25,19.38,618.77,,141.47,,,percent of total billed charges,,,47.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,242.25,,,percent of total billed charges,,,213.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,213.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,213.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,88.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,218.03,,,percent of total billed charges,,,,,,,,,242.25,,,percent of total billed charges,,,164.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.05,,,percent of total billed charges,,,,,,,,,,,,,,,130.81,,,percent of total billed charges,,,130.81,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.31,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.11,,,percent of total billed charges,,,91.76,,,percent of total billed charges,,,125.46,,,percent of total billed charges,,,,,,,,,,,,,,,48.45,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,89.63,,,percent of total billed charges,,,89.63,,,percent of total billed charges,,,242.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,242.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.38,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,242.25,,,fee schedule,,,225.34,,,percent of total billed charges,,,,,,,,,,,,,,,225.34,,,percent of total billed charges,,,225.34,,,percent of total billed charges,,,225.34,,,percent of total billed charges,,,181.69,,,percent of total billed charges,,,242.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,242.25,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,170.11,,,percent of total billed charges,,
EMTRICITABINE/TENOFOV/ALAFENAM,2500032357,CDM,637,RC,6195820021,NDC,999,EAPG,,,,outpatient,facility,1,UN,242.25,242.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FAMOTIDINE SUSP 8 MG/ML UDL,2500032363,CDM,637,RC,6818015001,NDC,,,,,,inpatient,facility,1,UN,11.68,11.68,0.93,11.68,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.51,,,percent of total billed charges,,,,,,,,,11.68,,,percent of total billed charges,,,6.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,,6.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.2,,,percent of total billed charges,,
FAMOTIDINE SUSP 8 MG/ML UDL,2500032363,CDM,637,RC,6818015001,NDC,,,,,,outpatient,facility,1,UN,11.68,11.68,0.93,618.77,,6.82,,,percent of total billed charges,,,2.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,11.68,,,percent of total billed charges,,,10.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,10.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,10.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,4.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,10.51,,,percent of total billed charges,,,,,,,,,11.68,,,percent of total billed charges,,,7.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.97,,,percent of total billed charges,,,,,,,,,,,,,,,6.31,,,percent of total billed charges,,,6.31,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.09,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.88,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,6.05,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,4.32,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.93,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,,,,,,,11.68,,,fee schedule,,,10.86,,,percent of total billed charges,,,,,,,,,,,,,,,10.86,,,percent of total billed charges,,,10.86,,,percent of total billed charges,,,10.86,,,percent of total billed charges,,,8.76,,,percent of total billed charges,,,11.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,11.68,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8.2,,,percent of total billed charges,,
FAMOTIDINE SUSP 8 MG/ML UDL,2500032363,CDM,637,RC,6818015001,NDC,999,EAPG,,,,outpatient,facility,1,UN,11.68,11.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUORESCEIN SODIUM 0.6 MG OPHT,2500032366,CDM,637,RC,1747840303,NDC,,,,,,inpatient,facility,0.6,UN,0.5,0.5,0.04,0.5,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,
FLUORESCEIN SODIUM 0.6 MG OPHT,2500032366,CDM,637,RC,1747840303,NDC,,,,,,outpatient,facility,0.6,UN,0.5,0.5,0.04,618.77,,0.29,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.5,,,percent of total billed charges,,,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.45,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.18,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,0.5,,,fee schedule,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,0.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.35,,,percent of total billed charges,,
FLUORESCEIN SODIUM 0.6 MG OPHT,2500032366,CDM,637,RC,1747840303,NDC,999,EAPG,,,,outpatient,facility,0.6,UN,0.5,0.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FUROSEMIDE 250 MG/50 ML BAG,2500032367,CDM,636,RC,J1940,HCPCS,3600028425,NDC,,,,inpatient,facility,50,UN,29.37,29.37,2.35,29.37,,,,,,,,,,,,,,29.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.43,,,percent of total billed charges,,,,,,,,,29.37,,,percent of total billed charges,,,16.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.37,,,percent of total billed charges,,,,,,,,,,,,,,,29.37,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,29.37,,,percent of total billed charges,,,29.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.62,,,percent of total billed charges,,
FUROSEMIDE 250 MG/50 ML BAG,2500032367,CDM,636,RC,J1940,HCPCS,3600028425,NDC,,,,outpatient,facility,50,UN,29.37,29.37,0.45,618.77,,17.15,,,percent of total billed charges,,,5.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,29.37,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,29.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,26.43,,,percent of total billed charges,,,,,,,,,29.37,,,percent of total billed charges,,,19.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,29.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,29.37,,,percent of total billed charges,,,29.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.32,,,percent of total billed charges,,,11.13,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,29.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.35,,,percent of total billed charges,,,29.37,,,percent of total billed charges,,,29.37,,,percent of total billed charges,,,,,,,,,,,,,,,29.37,,,percent of total billed charges,,,29.37,,,percent of total billed charges,,,,,,,,,29.37,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.45,,,fee schedule,,,29.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,29.37,,,percent of total billed charges,,,29.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,20.62,,,percent of total billed charges,,
FUROSEMIDE 250 MG/50 ML BAG,2500032367,CDM,636,RC,J1940,HCPCS,3600028425,NDC,999,EAPG,,outpatient,facility,50,UN,29.37,29.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
hydroCHLOROthiazide 12.5MG TAB,2500032369,CDM,637,RC,6068768301,NDC,,,,,,inpatient,facility,12.5,UN,0.46,0.46,0.04,0.46,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,
hydroCHLOROthiazide 12.5MG TAB,2500032369,CDM,637,RC,6068768301,NDC,,,,,,outpatient,facility,12.5,UN,0.46,0.46,0.04,618.77,,0.27,,,percent of total billed charges,,,0.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,0.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.41,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.17,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.46,,,fee schedule,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,0.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.32,,,percent of total billed charges,,
hydroCHLOROthiazide 12.5MG TAB,2500032369,CDM,637,RC,6068768301,NDC,999,EAPG,,,,outpatient,facility,12.5,UN,0.46,0.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CHLORIDE 10 MEQ TABC,2500032374,CDM,637,RC,245531701,NDC,,,,,,inpatient,facility,10,UN,2.04,2.04,0.16,2.04,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,
POTASSIUM CHLORIDE 10 MEQ TABC,2500032374,CDM,637,RC,245531701,NDC,,,,,,outpatient,facility,10,UN,2.04,2.04,0.16,618.77,,1.19,,,percent of total billed charges,,,0.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.04,,,percent of total billed charges,,,1.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.84,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.75,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,2.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,2.04,,,fee schedule,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,2.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.43,,,percent of total billed charges,,
POTASSIUM CHLORIDE 10 MEQ TABC,2500032374,CDM,637,RC,245531701,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.04,2.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIDAZOLAM/NS 50 MG/50 ML BAG,2500032380,CDM,636,RC,J2250,HCPCS,4778158991,NDC,,,,inpatient,facility,50,UN,116.82,116.82,9.35,116.82,,,,,,,,,,,,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.14,,,percent of total billed charges,,,,,,,,,116.82,,,percent of total billed charges,,,64.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,116.82,,,percent of total billed charges,,,60.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.35,,,percent of total billed charges,,,116.82,,,percent of total billed charges,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.03,,,percent of total billed charges,,
MIDAZOLAM/NS 50 MG/50 ML BAG,2500032380,CDM,636,RC,J2250,HCPCS,4778158991,NDC,,,,outpatient,facility,50,UN,116.82,116.82,0.14,618.77,,68.22,,,percent of total billed charges,,,22.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,116.82,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,42.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,105.14,,,percent of total billed charges,,,,,,,,,116.82,,,percent of total billed charges,,,79.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.91,,,percent of total billed charges,,,116.82,,,percent of total billed charges,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.78,,,percent of total billed charges,,,44.25,,,percent of total billed charges,,,60.5,,,percent of total billed charges,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,116.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,116.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.35,,,percent of total billed charges,,,116.82,,,percent of total billed charges,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,116.82,,,percent of total billed charges,,,116.82,,,percent of total billed charges,,,,,,,,,116.82,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.14,,,fee schedule,,,116.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,116.82,,,percent of total billed charges,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,82.03,,,percent of total billed charges,,
MIDAZOLAM/NS 50 MG/50 ML BAG,2500032380,CDM,636,RC,J2250,HCPCS,4778158991,NDC,496,EAPG,,outpatient,facility,50,UN,116.82,116.82,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NOREPINEPHRINE/NS 16 MG/250 ML,2500032390,CDM,250,RC,4456764201,NDC,,,,,,inpatient,facility,250,UN,229.32,229.32,18.35,229.32,,,,,,,,,,,,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.39,,,percent of total billed charges,,,,,,,,,229.32,,,percent of total billed charges,,,126.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,229.32,,,percent of total billed charges,,,119.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.35,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.03,,,percent of total billed charges,,
NOREPINEPHRINE/NS 16 MG/250 ML,2500032390,CDM,250,RC,4456764201,NDC,,,,,,outpatient,facility,250,UN,229.32,229.32,18.35,618.77,,133.92,,,percent of total billed charges,,,44.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,229.32,,,percent of total billed charges,,,201.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,201.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,201.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,83.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,206.39,,,percent of total billed charges,,,,,,,,,229.32,,,percent of total billed charges,,,155.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.57,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.28,,,percent of total billed charges,,,86.87,,,percent of total billed charges,,,118.76,,,percent of total billed charges,,,,,,,,,,,,,,,45.86,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,91.73,,,percent of total billed charges,,,91.73,,,percent of total billed charges,,,229.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,229.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.35,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,229.32,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,,,,,,,229.32,,,fee schedule,,,91.73,,,percent of total billed charges,,,,,,,,,,,,,,,91.73,,,percent of total billed charges,,,91.73,,,percent of total billed charges,,,91.73,,,percent of total billed charges,,,171.99,,,percent of total billed charges,,,229.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,229.32,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,161.03,,,percent of total billed charges,,
NOREPINEPHRINE/NS 16 MG/250 ML,2500032390,CDM,250,RC,4456764201,NDC,999,EAPG,,,,outpatient,facility,250,UN,229.32,229.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NOREPINEPHRINE/NS 32 MG/250 ML,2500032391,CDM,250,RC,7032470201,NDC,,,,,,inpatient,facility,250,UN,231,231,18.48,231,,,,,,,,,,,,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.9,,,percent of total billed charges,,,,,,,,,231,,,percent of total billed charges,,,127.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,231,,,percent of total billed charges,,,120.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,231,,,percent of total billed charges,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.21,,,percent of total billed charges,,
NOREPINEPHRINE/NS 32 MG/250 ML,2500032391,CDM,250,RC,7032470201,NDC,,,,,,outpatient,facility,250,UN,231,231,18.48,618.77,,134.9,,,percent of total billed charges,,,45.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,231,,,percent of total billed charges,,,203.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,203.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,203.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,84.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,207.9,,,percent of total billed charges,,,,,,,,,231,,,percent of total billed charges,,,156.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,120.44,,,percent of total billed charges,,,231,,,percent of total billed charges,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.56,,,percent of total billed charges,,,87.5,,,percent of total billed charges,,,119.63,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,92.4,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,231,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,231,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.48,,,percent of total billed charges,,,231,,,percent of total billed charges,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,231,,,percent of total billed charges,,,231,,,percent of total billed charges,,,,,,,,,231,,,fee schedule,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,173.25,,,percent of total billed charges,,,231,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,231,,,percent of total billed charges,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,162.21,,,percent of total billed charges,,
NOREPINEPHRINE/NS 32 MG/250 ML,2500032391,CDM,250,RC,7032470201,NDC,999,EAPG,,,,outpatient,facility,250,UN,231,231,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMYLASE/LIPASE/PROTEASE 12000,2500032395,CDM,637,RC,32004770,NDC,,,,,,inpatient,facility,12000,UN,13.69,13.69,1.1,13.69,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.32,,,percent of total billed charges,,,,,,,,,13.69,,,percent of total billed charges,,,7.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,7.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.61,,,percent of total billed charges,,
AMYLASE/LIPASE/PROTEASE 12000,2500032395,CDM,637,RC,32004770,NDC,,,,,,outpatient,facility,12000,UN,13.69,13.69,1.1,618.77,,7.99,,,percent of total billed charges,,,2.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,13.69,,,percent of total billed charges,,,12.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,12.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,12.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,5.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,12.32,,,percent of total billed charges,,,,,,,,,13.69,,,percent of total billed charges,,,9.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.51,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.14,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.4,,,percent of total billed charges,,,5.19,,,percent of total billed charges,,,7.09,,,percent of total billed charges,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,5.07,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,13.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,13.69,,,fee schedule,,,12.73,,,percent of total billed charges,,,,,,,,,,,,,,,12.73,,,percent of total billed charges,,,12.73,,,percent of total billed charges,,,12.73,,,percent of total billed charges,,,10.27,,,percent of total billed charges,,,13.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,9.61,,,percent of total billed charges,,
AMYLASE/LIPASE/PROTEASE 12000,2500032395,CDM,637,RC,32004770,NDC,999,EAPG,,,,outpatient,facility,12000,UN,13.69,13.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMYLASE/LIPASE/PROTEASE 4200,2500032396,CDM,637,RC,6254140210,NDC,,,,,,inpatient,facility,4200,UN,3.96,3.96,0.32,3.96,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,3.96,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.78,,,percent of total billed charges,,
AMYLASE/LIPASE/PROTEASE 4200,2500032396,CDM,637,RC,6254140210,NDC,,,,,,outpatient,facility,4200,UN,3.96,3.96,0.32,618.77,,2.31,,,percent of total billed charges,,,0.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,3.96,,,percent of total billed charges,,,3.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,3.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,3.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,1.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3.56,,,percent of total billed charges,,,,,,,,,3.96,,,percent of total billed charges,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1.47,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,3.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.32,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,,,,,,,3.96,,,fee schedule,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,3.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3.96,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.78,,,percent of total billed charges,,
AMYLASE/LIPASE/PROTEASE 4200,2500032396,CDM,637,RC,6254140210,NDC,999,EAPG,,,,outpatient,facility,4200,UN,3.96,3.96,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMYLASE/LIPASE/PROTEASE 6000,2500032397,CDM,637,RC,32004670,NDC,,,,,,inpatient,facility,6000,UN,6.86,6.86,0.55,6.86,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.17,,,percent of total billed charges,,,,,,,,,6.86,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.82,,,percent of total billed charges,,
AMYLASE/LIPASE/PROTEASE 6000,2500032397,CDM,637,RC,32004670,NDC,,,,,,outpatient,facility,6000,UN,6.86,6.86,0.55,618.77,,4.01,,,percent of total billed charges,,,1.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,6.86,,,percent of total billed charges,,,6.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,6.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,6.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,6.17,,,percent of total billed charges,,,,,,,,,6.86,,,percent of total billed charges,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,3.7,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,3.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,6.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.55,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,6.86,,,fee schedule,,,6.38,,,percent of total billed charges,,,,,,,,,,,,,,,6.38,,,percent of total billed charges,,,6.38,,,percent of total billed charges,,,6.38,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,6.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.82,,,percent of total billed charges,,
AMYLASE/LIPASE/PROTEASE 6000,2500032397,CDM,637,RC,32004670,NDC,999,EAPG,,,,outpatient,facility,6000,UN,6.86,6.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
UMECLIDINIUM 62.5 MCG INH,2500032413,CDM,637,RC,173087306,NDC,,,,,,inpatient,facility,1,UN,35.37,35.37,2.83,35.37,,,,,,,,,,,,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.83,,,percent of total billed charges,,,,,,,,,35.37,,,percent of total billed charges,,,19.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,35.37,,,percent of total billed charges,,,18.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.83,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.84,,,percent of total billed charges,,
UMECLIDINIUM 62.5 MCG INH,2500032413,CDM,637,RC,173087306,NDC,,,,,,outpatient,facility,1,UN,35.37,35.37,2.83,618.77,,20.66,,,percent of total billed charges,,,6.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,35.37,,,percent of total billed charges,,,31.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,31.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,31.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,12.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,31.83,,,percent of total billed charges,,,,,,,,,35.37,,,percent of total billed charges,,,23.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,19.1,,,percent of total billed charges,,,19.1,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.44,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.88,,,percent of total billed charges,,,13.4,,,percent of total billed charges,,,18.32,,,percent of total billed charges,,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,13.09,,,percent of total billed charges,,,13.09,,,percent of total billed charges,,,35.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.83,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,35.37,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,,,,,,,35.37,,,fee schedule,,,32.9,,,percent of total billed charges,,,,,,,,,,,,,,,32.9,,,percent of total billed charges,,,32.9,,,percent of total billed charges,,,32.9,,,percent of total billed charges,,,26.53,,,percent of total billed charges,,,35.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,35.37,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,24.84,,,percent of total billed charges,,
UMECLIDINIUM 62.5 MCG INH,2500032413,CDM,637,RC,173087306,NDC,999,EAPG,,,,outpatient,facility,1,UN,35.37,35.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IPRATROPIUM/ALBUTEROL 4 GM INH,2500032443,CDM,637,RC,J3535,HCPCS,597002402,NDC,,,,inpatient,facility,4,UN,1614.82,1614.82,129.19,1614.82,,,,,,,,,,,,,,1614.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1453.34,,,percent of total billed charges,,,,,,,,,1614.82,,,percent of total billed charges,,,893.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1473.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1614.82,,,percent of total billed charges,,,,,,,,,,,,,,,1614.82,,,percent of total billed charges,,,841.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,322.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.19,,,percent of total billed charges,,,1614.82,,,percent of total billed charges,,,1614.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1614.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1133.93,,,percent of total billed charges,,
IPRATROPIUM/ALBUTEROL 4 GM INH,2500032443,CDM,637,RC,J3535,HCPCS,597002402,NDC,,,,outpatient,facility,4,UN,1614.82,1614.82,2.48,1614.82,,943.05,,,percent of total billed charges,,,314.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1614.82,,,percent of total billed charges,,,1421.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1421.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1421.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1614.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,591.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1453.34,,,percent of total billed charges,,,,,,,,,1614.82,,,percent of total billed charges,,,1093.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1240.18,,,percent of total billed charges,,,,,,,,,,,,,,,872,,,percent of total billed charges,,,872,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1614.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,841.97,,,percent of total billed charges,,,1614.82,,,percent of total billed charges,,,1614.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1227.26,,,percent of total billed charges,,,611.69,,,percent of total billed charges,,,836.32,,,percent of total billed charges,,,,,,,,,,,,,,,322.96,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,8.03,,,fee schedule,,,3.58,,,fee schedule,,,1614.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1614.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,129.19,,,percent of total billed charges,,,1614.82,,,percent of total billed charges,,,1614.82,,,percent of total billed charges,,,,,,,,,,,,,,,1614.82,,,percent of total billed charges,,,1614.82,,,percent of total billed charges,,,,,,,,,1614.82,,,fee schedule,,,3.82,,,fee schedule,,,,,,,,,,,,,,,3.36,,,fee schedule,,,4.48,,,fee schedule,,,2.48,,,fee schedule,,,1211.12,,,percent of total billed charges,,,1614.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1614.82,,,percent of total billed charges,,,1614.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,807.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1133.93,,,percent of total billed charges,,
IPRATROPIUM/ALBUTEROL 4 GM INH,2500032443,CDM,637,RC,J3535,HCPCS,597002402,NDC,999,EAPG,,outpatient,facility,4,UN,1614.82,1614.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MOMETASONE/FORMOT 200/5MCG INH,2500032510,CDM,637,RC,85461005,NDC,,,,,,inpatient,facility,8.8,UN,695.51,695.51,55.64,695.51,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,625.96,,,percent of total billed charges,,,,,,,,,695.51,,,percent of total billed charges,,,385.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,634.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,362.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.64,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,488.39,,,percent of total billed charges,,
MOMETASONE/FORMOT 200/5MCG INH,2500032510,CDM,637,RC,85461005,NDC,,,,,,outpatient,facility,8.8,UN,695.51,695.51,55.64,695.51,,406.18,,,percent of total billed charges,,,135.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,695.51,,,percent of total billed charges,,,612.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,612.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,612.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,254.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,625.96,,,percent of total billed charges,,,,,,,,,695.51,,,percent of total billed charges,,,471,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.15,,,percent of total billed charges,,,,,,,,,,,,,,,375.58,,,percent of total billed charges,,,375.58,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,362.64,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,528.59,,,percent of total billed charges,,,263.46,,,percent of total billed charges,,,360.2,,,percent of total billed charges,,,,,,,,,,,,,,,139.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,257.34,,,percent of total billed charges,,,257.34,,,percent of total billed charges,,,695.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,695.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,55.64,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,,,,,,,695.51,,,fee schedule,,,646.96,,,percent of total billed charges,,,,,,,,,,,,,,,646.96,,,percent of total billed charges,,,646.96,,,percent of total billed charges,,,646.96,,,percent of total billed charges,,,521.63,,,percent of total billed charges,,,695.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,695.51,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,347.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,488.39,,,percent of total billed charges,,
MOMETASONE/FORMOT 200/5MCG INH,2500032510,CDM,637,RC,85461005,NDC,999,EAPG,,,,outpatient,facility,8.8,UN,695.51,695.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MULTIVITAMINS LIQ 15 ML UDC,2500032533,CDM,637,RC,5434462,NDC,,,,,,inpatient,facility,15,UN,1.89,1.89,0.15,1.89,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,1.89,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,
MULTIVITAMINS LIQ 15 ML UDC,2500032533,CDM,637,RC,5434462,NDC,,,,,,outpatient,facility,15,UN,1.89,1.89,0.15,618.77,,1.1,,,percent of total billed charges,,,0.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1.89,,,percent of total billed charges,,,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1.7,,,percent of total billed charges,,,,,,,,,1.89,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.7,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,1.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,,,,,,,1.89,,,fee schedule,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,1.76,,,percent of total billed charges,,,1.76,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1.89,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.33,,,percent of total billed charges,,
MULTIVITAMINS LIQ 15 ML UDC,2500032533,CDM,637,RC,5434462,NDC,999,EAPG,,,,outpatient,facility,15,UN,1.89,1.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 2  JELLY 6 ML,2500032540,CDM,637,RC,2502167376,NDC,,,,,,inpatient,facility,6,UN,19.64,19.64,1.57,19.64,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.68,,,percent of total billed charges,,,,,,,,,19.64,,,percent of total billed charges,,,10.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,10.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.79,,,percent of total billed charges,,
LIDOCAINE HCL 2  JELLY 6 ML,2500032540,CDM,637,RC,2502167376,NDC,,,,,,outpatient,facility,6,UN,19.64,19.64,1.57,618.77,,11.47,,,percent of total billed charges,,,3.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,19.64,,,percent of total billed charges,,,17.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,17.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,17.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,17.68,,,percent of total billed charges,,,,,,,,,19.64,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.08,,,percent of total billed charges,,,,,,,,,,,,,,,10.61,,,percent of total billed charges,,,10.61,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.24,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.93,,,percent of total billed charges,,,7.44,,,percent of total billed charges,,,10.17,,,percent of total billed charges,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.27,,,percent of total billed charges,,,7.27,,,percent of total billed charges,,,19.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.57,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,19.64,,,fee schedule,,,18.27,,,percent of total billed charges,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,14.73,,,percent of total billed charges,,,19.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,19.64,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,13.79,,,percent of total billed charges,,
LIDOCAINE HCL 2  JELLY 6 ML,2500032540,CDM,637,RC,2502167376,NDC,999,EAPG,,,,outpatient,facility,6,UN,19.64,19.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INFLUENZA FLUCELVAX Q PF 0.5ML,2500032542,CDM,636,RC,90674,CPT,,,,,,inpatient,facility,1,UN,96.86,96.86,7.75,96.86,,,,,,,,,,,,,,96.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.17,,,percent of total billed charges,,,,,,,,,96.86,,,percent of total billed charges,,,53.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.86,,,percent of total billed charges,,,,,,,,,,,,,,,96.86,,,percent of total billed charges,,,50.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.75,,,percent of total billed charges,,,96.86,,,percent of total billed charges,,,96.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.02,,,percent of total billed charges,,
INFLUENZA FLUCELVAX Q PF 0.5ML,2500032542,CDM,636,RC,90674,CPT,,,,,,outpatient,facility,1,UN,96.86,96.86,7.75,618.77,,56.57,,,percent of total billed charges,,,28.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,96.86,,,percent of total billed charges,,,40.39,,,fee schedule,,,38.92,,,fee schedule,,,27.53,,,fee schedule,,,38.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,96.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.81,,,fee schedule,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,27.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,87.17,,,percent of total billed charges,,,27.53,,,fee schedule,,,96.86,,,percent of total billed charges,,,65.59,,,percent of total billed charges,,,28.9,,,fee schedule,,,28.91,,,fee schedule,,,,,,,,,27.53,,,fee schedule,,,27.53,,,fee schedule,,,28.91,,,fee schedule,,,74.39,,,percent of total billed charges,,,,,,,,,39.92,,,fee schedule,,,34.17,,,fee schedule,,,34.17,,,fee schedule,,,28.35,,,fee schedule,,,618.77,,,per diem,,,96.86,,,percent of total billed charges,,,26.57,,,fee schedule,,,29.46,,,fee schedule,,,29.49,,,fee schedule,,,50.5,,,percent of total billed charges,,,96.86,,,percent of total billed charges,,,96.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.53,,,fee schedule,,,27.53,,,fee schedule,,,73.61,,,percent of total billed charges,,,36.69,,,percent of total billed charges,,,50.16,,,percent of total billed charges,,,,,,,,,29.21,,,fee schedule,,,19.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,71.24,,,fee schedule,,,31.76,,,fee schedule,,,34.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,34.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.75,,,percent of total billed charges,,,96.86,,,percent of total billed charges,,,96.86,,,percent of total billed charges,,,27.53,,,fee schedule,,,27.53,,,fee schedule,,,96.86,,,percent of total billed charges,,,96.86,,,percent of total billed charges,,,27.53,,,fee schedule,,,96.86,,,fee schedule,,,33.89,,,fee schedule,,,27.53,,,fee schedule,,,28.36,,,fee schedule,,,29.81,,,fee schedule,,,39.74,,,fee schedule,,,22.03,,,fee schedule,,,35.46,,,fee schedule,,,96.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,96.86,,,percent of total billed charges,,,96.86,,,percent of total billed charges,,,30.58,,,fee schedule,,,27.53,,,fee schedule,,,29.35,,,fee schedule,,,27.53,,,fee schedule,,,27.53,,,fee schedule,,,28.09,,,fee schedule,,,48.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,28.09,,,fee schedule,,,68.02,,,percent of total billed charges,,
INFLUENZA FLUCELVAX Q PF 0.5ML,2500032542,CDM,636,RC,90674,CPT,414,EAPG,,,,outpatient,facility,1,UN,96.86,96.86,23.83,34.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.93,,,fee schedule,,,23.83,,,fee schedule,,,31.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SP-BOTULINUM TOXIN A 100 UNITS,2500032551,CDM,636,RC,J0585,HCPCS,23114501,NDC,,,,inpatient,facility,100,UN,0.04,0.04,0.01,0.04,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,,,,,,,0.04,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,0.04,,,percent of total billed charges,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,
SP-BOTULINUM TOXIN A 100 UNITS,2500032551,CDM,636,RC,J0585,HCPCS,23114501,NDC,,,,outpatient,facility,100,UN,0.04,0.04,0.01,618.77,,0.02,,,percent of total billed charges,,,,,,,,,0.04,,,percent of total billed charges,,,7.54,,,fee schedule,,,7.27,,,fee schedule,,,,,,,,,7.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.04,,,percent of total billed charges,,,,,,,,,0.04,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,fee schedule,,,0.04,,,fee schedule,,,,,,,,,618.77,,,per diem,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.04,,,percent of total billed charges,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.04,,,fee schedule,,,0.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,0.04,,,percent of total billed charges,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.04,,,percent of total billed charges,,,,,,,,,0.04,,,fee schedule,,,0.04,,,fee schedule,,,,,,,,,,,,,,,0.04,,,fee schedule,,,0.04,,,fee schedule,,,0.04,,,fee schedule,,,0.04,,,fee schedule,,,0.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.04,,,percent of total billed charges,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.03,,,percent of total billed charges,,
SP-BOTULINUM TOXIN A 100 UNITS,2500032551,CDM,636,RC,J0585,HCPCS,23114501,NDC,902,APC,,outpatient,facility,100,UN,0.04,0.04,0.01,9.38,,,,,,,,6.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.53,,,fee schedule,,,,,,,,,0.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,6.47,,,fee schedule,,,,,,,,,,,,,,,6.47,,,fee schedule,,,6.79,,,fee schedule,,,,,,,,,6.47,,,fee schedule,,,6.47,,,fee schedule,,,6.79,,,fee schedule,,,,,,,,,,,,,,,9.38,,,fee schedule,,,,,,,,,,,,,,,6.47,,,fee schedule,,,,,,,,,,,,,,,6.21,,,fee schedule,,,6.92,,,fee schedule,,,6.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.47,,,fee schedule,,,6.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.47,,,fee schedule,,,6.47,,,fee schedule,,,,,,,,,,,,,,,6.47,,,fee schedule,,,,,,,,,,,,,,,6.47,,,fee schedule,,,6.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.41,,,fee schedule,,,6.47,,,fee schedule,,,6.73,,,fee schedule,,,6.47,,,fee schedule,,,,,,,,,6.47,,,fee schedule,,,,,,,,,6.47,,,fee schedule,,,,,,,,
SP-BOTULINUM TOXIN A 100 UNITS,2500032551,CDM,636,RC,J0585,HCPCS,23114501,NDC,439,EAPG,,outpatient,facility,100,UN,0.04,0.04,767.47,1125.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.11,,,fee schedule,,,767.47,,,fee schedule,,,1000.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,767.47,,,fee schedule,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,767.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
UMECLIDINIUM/VILANTEROL 7 PUFF,2500032556,CDM,637,RC,173086906,NDC,,,,,,inpatient,facility,7,UN,26.9,26.9,2.15,26.9,,,,,,,,,,,,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.21,,,percent of total billed charges,,,,,,,,,26.9,,,percent of total billed charges,,,14.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,26.9,,,percent of total billed charges,,,14.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.89,,,percent of total billed charges,,
UMECLIDINIUM/VILANTEROL 7 PUFF,2500032556,CDM,637,RC,173086906,NDC,,,,,,outpatient,facility,7,UN,26.9,26.9,2.15,618.77,,15.71,,,percent of total billed charges,,,5.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,26.9,,,percent of total billed charges,,,23.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,23.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,23.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,24.21,,,percent of total billed charges,,,,,,,,,26.9,,,percent of total billed charges,,,18.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.66,,,percent of total billed charges,,,,,,,,,,,,,,,14.53,,,percent of total billed charges,,,14.53,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.03,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.44,,,percent of total billed charges,,,10.19,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,9.95,,,percent of total billed charges,,,9.95,,,percent of total billed charges,,,26.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.15,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,26.9,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,,,,,,,26.9,,,fee schedule,,,25.02,,,percent of total billed charges,,,,,,,,,,,,,,,25.02,,,percent of total billed charges,,,25.02,,,percent of total billed charges,,,25.02,,,percent of total billed charges,,,20.17,,,percent of total billed charges,,,26.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,26.9,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,18.89,,,percent of total billed charges,,
UMECLIDINIUM/VILANTEROL 7 PUFF,2500032556,CDM,637,RC,173086906,NDC,999,EAPG,,,,outpatient,facility,7,UN,26.9,26.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPOFOL IV 10 MG/ML 10 ML AMP,2500032558,CDM,636,RC,J2704,HCPCS,6332326910,NDC,,,,inpatient,facility,10,ML,9.9,9.9,0.79,9.9,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,5.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.95,,,percent of total billed charges,,
PROPOFOL IV 10 MG/ML 10 ML AMP,2500032558,CDM,636,RC,J2704,HCPCS,6332326910,NDC,,,,outpatient,facility,10,ML,9.9,9.9,0.09,618.77,,5.78,,,percent of total billed charges,,,1.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,9.9,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,8.91,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.16,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.52,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,9.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,9.9,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,9.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,6.95,,,percent of total billed charges,,
PROPOFOL IV 10 MG/ML 10 ML AMP,2500032558,CDM,636,RC,J2704,HCPCS,6332326910,NDC,496,EAPG,,outpatient,facility,10,ML,9.9,9.9,141.05,206.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.78,,,fee schedule,,,141.05,,,fee schedule,,,183.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOTIFEN 0.25  OPTH 5 ML BTL,2500032581,CDM,637,RC,1747871710,NDC,,,,,,inpatient,facility,5,UN,40.23,40.23,3.22,40.23,,,,,,,,,,,,,,40.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.21,,,percent of total billed charges,,,,,,,,,40.23,,,percent of total billed charges,,,22.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.23,,,percent of total billed charges,,,,,,,,,,,,,,,40.23,,,percent of total billed charges,,,20.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,40.23,,,percent of total billed charges,,,40.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,
KETOTIFEN 0.25  OPTH 5 ML BTL,2500032581,CDM,637,RC,1747871710,NDC,,,,,,outpatient,facility,5,UN,40.23,40.23,3.22,618.77,,23.49,,,percent of total billed charges,,,7.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,40.23,,,percent of total billed charges,,,35.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,35.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,35.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,40.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,14.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,36.21,,,percent of total billed charges,,,,,,,,,40.23,,,percent of total billed charges,,,27.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.9,,,percent of total billed charges,,,,,,,,,,,,,,,21.72,,,percent of total billed charges,,,21.72,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,40.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.98,,,percent of total billed charges,,,40.23,,,percent of total billed charges,,,40.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.57,,,percent of total billed charges,,,15.24,,,percent of total billed charges,,,20.84,,,percent of total billed charges,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,14.89,,,percent of total billed charges,,,14.89,,,percent of total billed charges,,,40.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.22,,,percent of total billed charges,,,40.23,,,percent of total billed charges,,,40.23,,,percent of total billed charges,,,,,,,,,,,,,,,40.23,,,percent of total billed charges,,,40.23,,,percent of total billed charges,,,,,,,,,40.23,,,fee schedule,,,37.42,,,percent of total billed charges,,,,,,,,,,,,,,,37.42,,,percent of total billed charges,,,37.42,,,percent of total billed charges,,,37.42,,,percent of total billed charges,,,30.17,,,percent of total billed charges,,,40.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,40.23,,,percent of total billed charges,,,40.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.11,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,28.25,,,percent of total billed charges,,
KETOTIFEN 0.25  OPTH 5 ML BTL,2500032581,CDM,637,RC,1747871710,NDC,999,EAPG,,,,outpatient,facility,5,UN,40.23,40.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MOMETASONE 200 MCG PUFF CAN,2500032583,CDM,637,RC,7820611301,NDC,,,,,,inpatient,facility,1,UN,59.89,59.89,4.79,59.89,,,,,,,,,,,,,,59.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.9,,,percent of total billed charges,,,,,,,,,59.89,,,percent of total billed charges,,,33.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.89,,,percent of total billed charges,,,,,,,,,,,,,,,59.89,,,percent of total billed charges,,,31.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.79,,,percent of total billed charges,,,59.89,,,percent of total billed charges,,,59.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.05,,,percent of total billed charges,,
MOMETASONE 200 MCG PUFF CAN,2500032583,CDM,637,RC,7820611301,NDC,,,,,,outpatient,facility,1,UN,59.89,59.89,4.79,618.77,,34.98,,,percent of total billed charges,,,11.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,59.89,,,percent of total billed charges,,,52.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,52.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,52.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,59.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,21.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,53.9,,,percent of total billed charges,,,,,,,,,59.89,,,percent of total billed charges,,,40.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46,,,percent of total billed charges,,,,,,,,,,,,,,,32.34,,,percent of total billed charges,,,32.34,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,59.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.23,,,percent of total billed charges,,,59.89,,,percent of total billed charges,,,59.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.52,,,percent of total billed charges,,,22.69,,,percent of total billed charges,,,31.02,,,percent of total billed charges,,,,,,,,,,,,,,,11.98,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,22.16,,,percent of total billed charges,,,22.16,,,percent of total billed charges,,,59.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,59.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.79,,,percent of total billed charges,,,59.89,,,percent of total billed charges,,,59.89,,,percent of total billed charges,,,,,,,,,,,,,,,59.89,,,percent of total billed charges,,,59.89,,,percent of total billed charges,,,,,,,,,59.89,,,fee schedule,,,55.71,,,percent of total billed charges,,,,,,,,,,,,,,,55.71,,,percent of total billed charges,,,55.71,,,percent of total billed charges,,,55.71,,,percent of total billed charges,,,44.92,,,percent of total billed charges,,,59.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,59.89,,,percent of total billed charges,,,59.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,42.05,,,percent of total billed charges,,
MOMETASONE 200 MCG PUFF CAN,2500032583,CDM,637,RC,7820611301,NDC,999,EAPG,,,,outpatient,facility,1,UN,59.89,59.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MOMETASONE 200MCG 13GM INH,2500032584,CDM,637,RC,7820611301,NDC,,,,,,inpatient,facility,13,UN,890.6,890.6,71.25,890.6,,,,,,,,,,,,,,890.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,801.54,,,percent of total billed charges,,,,,,,,,890.6,,,percent of total billed charges,,,493.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,812.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,890.6,,,percent of total billed charges,,,,,,,,,,,,,,,890.6,,,percent of total billed charges,,,464.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.25,,,percent of total billed charges,,,890.6,,,percent of total billed charges,,,890.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,890.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,625.38,,,percent of total billed charges,,
MOMETASONE 200MCG 13GM INH,2500032584,CDM,637,RC,7820611301,NDC,,,,,,outpatient,facility,13,UN,890.6,890.6,71.25,890.6,,520.11,,,percent of total billed charges,,,173.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,890.6,,,percent of total billed charges,,,784.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,784.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,784.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,890.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,325.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,801.54,,,percent of total billed charges,,,,,,,,,890.6,,,percent of total billed charges,,,603.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,683.98,,,percent of total billed charges,,,,,,,,,,,,,,,480.92,,,percent of total billed charges,,,480.92,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,890.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,464.36,,,percent of total billed charges,,,890.6,,,percent of total billed charges,,,890.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.86,,,percent of total billed charges,,,337.36,,,percent of total billed charges,,,461.24,,,percent of total billed charges,,,,,,,,,,,,,,,178.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,329.52,,,percent of total billed charges,,,329.52,,,percent of total billed charges,,,890.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,890.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,71.25,,,percent of total billed charges,,,890.6,,,percent of total billed charges,,,890.6,,,percent of total billed charges,,,,,,,,,,,,,,,890.6,,,percent of total billed charges,,,890.6,,,percent of total billed charges,,,,,,,,,890.6,,,fee schedule,,,828.44,,,percent of total billed charges,,,,,,,,,,,,,,,828.44,,,percent of total billed charges,,,828.44,,,percent of total billed charges,,,828.44,,,percent of total billed charges,,,667.95,,,percent of total billed charges,,,890.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,890.6,,,percent of total billed charges,,,890.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,445.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,625.38,,,percent of total billed charges,,
MOMETASONE 200MCG 13GM INH,2500032584,CDM,637,RC,7820611301,NDC,999,EAPG,,,,outpatient,facility,13,UN,890.6,890.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHADONE ORAL 10 mg/ml,2500032593,CDM,250,RC,S0109,HCPCS,6668969479,NDC,,,,inpatient,facility,1,UN,0.33,0.33,0.03,0.33,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,0.33,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,
METHADONE ORAL 10 mg/ml,2500032593,CDM,250,RC,S0109,HCPCS,6668969479,NDC,,,,outpatient,facility,1,UN,0.33,0.33,0.03,618.77,,0.19,,,percent of total billed charges,,,0.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.33,,,percent of total billed charges,,,0.41,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.3,,,percent of total billed charges,,,,,,,,,0.33,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,fee schedule,,,0.31,,,fee schedule,,,,,,,,,618.77,,,per diem,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.33,,,fee schedule,,,0.28,,,fee schedule,,,0.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,0.33,,,fee schedule,,,0.29,,,fee schedule,,,,,,,,,,,,,,,0.26,,,fee schedule,,,0.33,,,fee schedule,,,0.19,,,fee schedule,,,0.33,,,fee schedule,,,0.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.23,,,percent of total billed charges,,
METHADONE ORAL 10 mg/ml,2500032593,CDM,250,RC,S0109,HCPCS,6668969479,NDC,999,EAPG,,outpatient,facility,1,UN,0.33,0.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FISH OIL 500 MG CAP,2500032631,CDM,637,RC,5293700340,NDC,,,,,,inpatient,facility,500,UN,5.71,5.71,0.46,5.71,,,,,,,,,,,,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.14,,,percent of total billed charges,,,,,,,,,5.71,,,percent of total billed charges,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,5.71,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,
FISH OIL 500 MG CAP,2500032631,CDM,637,RC,5293700340,NDC,,,,,,outpatient,facility,500,UN,5.71,5.71,0.46,618.77,,3.33,,,percent of total billed charges,,,1.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,5.71,,,percent of total billed charges,,,5.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,5.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,5.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,2.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5.14,,,percent of total billed charges,,,,,,,,,5.71,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.39,,,percent of total billed charges,,,,,,,,,,,,,,,3.08,,,percent of total billed charges,,,3.08,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.34,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,2.96,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,5.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,5.71,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,,,,,,,5.71,,,fee schedule,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,4.28,,,percent of total billed charges,,,5.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,5.71,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4.01,,,percent of total billed charges,,
FISH OIL 500 MG CAP,2500032631,CDM,637,RC,5293700340,NDC,999,EAPG,,,,outpatient,facility,500,UN,5.71,5.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ONDANSETRON HCL ODT 4MG,2500032638,CDM,637,RC,6846215713,NDC,,,,,,inpatient,facility,4,UN,76.26,76.26,6.1,76.26,,,,,,,,,,,,,,76.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.63,,,percent of total billed charges,,,,,,,,,76.26,,,percent of total billed charges,,,42.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.26,,,percent of total billed charges,,,,,,,,,,,,,,,76.26,,,percent of total billed charges,,,39.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.1,,,percent of total billed charges,,,76.26,,,percent of total billed charges,,,76.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,76.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.55,,,percent of total billed charges,,
ONDANSETRON HCL ODT 4MG,2500032638,CDM,637,RC,6846215713,NDC,,,,,,outpatient,facility,4,UN,76.26,76.26,6.1,618.77,,44.54,,,percent of total billed charges,,,14.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,76.26,,,percent of total billed charges,,,67.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,67.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,67.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,76.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,27.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,68.63,,,percent of total billed charges,,,,,,,,,76.26,,,percent of total billed charges,,,51.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.57,,,percent of total billed charges,,,,,,,,,,,,,,,41.18,,,percent of total billed charges,,,41.18,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,76.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.76,,,percent of total billed charges,,,76.26,,,percent of total billed charges,,,76.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.96,,,percent of total billed charges,,,28.89,,,percent of total billed charges,,,39.5,,,percent of total billed charges,,,,,,,,,,,,,,,15.25,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,28.22,,,percent of total billed charges,,,28.22,,,percent of total billed charges,,,76.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,76.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.1,,,percent of total billed charges,,,76.26,,,percent of total billed charges,,,76.26,,,percent of total billed charges,,,,,,,,,,,,,,,76.26,,,percent of total billed charges,,,76.26,,,percent of total billed charges,,,,,,,,,76.26,,,fee schedule,,,70.94,,,percent of total billed charges,,,,,,,,,,,,,,,70.94,,,percent of total billed charges,,,70.94,,,percent of total billed charges,,,70.94,,,percent of total billed charges,,,57.2,,,percent of total billed charges,,,76.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,76.26,,,percent of total billed charges,,,76.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,53.55,,,percent of total billed charges,,
ONDANSETRON HCL ODT 4MG,2500032638,CDM,637,RC,6846215713,NDC,999,EAPG,,,,outpatient,facility,4,UN,76.26,76.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARIPRAZINE 1.5 MG CAP,2500032646,CDM,637,RC,6187411530,NDC,,,,,,inpatient,facility,1.5,UN,159.12,159.12,12.73,159.12,,,,,,,,,,,,,,159.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.21,,,percent of total billed charges,,,,,,,,,159.12,,,percent of total billed charges,,,88.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.12,,,percent of total billed charges,,,,,,,,,,,,,,,159.12,,,percent of total billed charges,,,82.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.73,,,percent of total billed charges,,,159.12,,,percent of total billed charges,,,159.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,159.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.73,,,percent of total billed charges,,
CARIPRAZINE 1.5 MG CAP,2500032646,CDM,637,RC,6187411530,NDC,,,,,,outpatient,facility,1.5,UN,159.12,159.12,12.73,618.77,,92.93,,,percent of total billed charges,,,31.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,159.12,,,percent of total billed charges,,,140.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,140.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,140.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,159.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,58.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,143.21,,,percent of total billed charges,,,,,,,,,159.12,,,percent of total billed charges,,,107.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.2,,,percent of total billed charges,,,,,,,,,,,,,,,85.92,,,percent of total billed charges,,,85.92,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,159.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.97,,,percent of total billed charges,,,159.12,,,percent of total billed charges,,,159.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.93,,,percent of total billed charges,,,60.27,,,percent of total billed charges,,,82.41,,,percent of total billed charges,,,,,,,,,,,,,,,31.82,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,58.87,,,percent of total billed charges,,,58.87,,,percent of total billed charges,,,159.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,159.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.73,,,percent of total billed charges,,,159.12,,,percent of total billed charges,,,159.12,,,percent of total billed charges,,,,,,,,,,,,,,,159.12,,,percent of total billed charges,,,159.12,,,percent of total billed charges,,,,,,,,,159.12,,,fee schedule,,,148.01,,,percent of total billed charges,,,,,,,,,,,,,,,148.01,,,percent of total billed charges,,,148.01,,,percent of total billed charges,,,148.01,,,percent of total billed charges,,,119.34,,,percent of total billed charges,,,159.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,159.12,,,percent of total billed charges,,,159.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,111.73,,,percent of total billed charges,,
CARIPRAZINE 1.5 MG CAP,2500032646,CDM,637,RC,6187411530,NDC,999,EAPG,,,,outpatient,facility,1.5,UN,159.12,159.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AQUAPHOR OINT 50 GM,2500032662,CDM,637,RC,7214045231,NDC,,,,,,inpatient,facility,50,UN,28.35,28.35,2.27,28.35,,,,,,,,,,,,,,28.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.52,,,percent of total billed charges,,,,,,,,,28.35,,,percent of total billed charges,,,15.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.35,,,percent of total billed charges,,,,,,,,,,,,,,,28.35,,,percent of total billed charges,,,14.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.27,,,percent of total billed charges,,,28.35,,,percent of total billed charges,,,28.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.91,,,percent of total billed charges,,
AQUAPHOR OINT 50 GM,2500032662,CDM,637,RC,7214045231,NDC,,,,,,outpatient,facility,50,UN,28.35,28.35,2.27,618.77,,16.56,,,percent of total billed charges,,,5.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,28.35,,,percent of total billed charges,,,24.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,24.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,24.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,28.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,10.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,25.52,,,percent of total billed charges,,,,,,,,,28.35,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.77,,,percent of total billed charges,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,28.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.78,,,percent of total billed charges,,,28.35,,,percent of total billed charges,,,28.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.55,,,percent of total billed charges,,,10.74,,,percent of total billed charges,,,14.68,,,percent of total billed charges,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,10.49,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,28.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.27,,,percent of total billed charges,,,28.35,,,percent of total billed charges,,,28.35,,,percent of total billed charges,,,,,,,,,,,,,,,28.35,,,percent of total billed charges,,,28.35,,,percent of total billed charges,,,,,,,,,28.35,,,fee schedule,,,26.37,,,percent of total billed charges,,,,,,,,,,,,,,,26.37,,,percent of total billed charges,,,26.37,,,percent of total billed charges,,,26.37,,,percent of total billed charges,,,21.26,,,percent of total billed charges,,,28.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,28.35,,,percent of total billed charges,,,28.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,19.91,,,percent of total billed charges,,
AQUAPHOR OINT 50 GM,2500032662,CDM,637,RC,7214045231,NDC,999,EAPG,,,,outpatient,facility,50,UN,28.35,28.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIRABEGRON ER 25 MG TAB,2500032668,CDM,637,RC,469260130,NDC,,,,,,inpatient,facility,25,UN,50.62,50.62,4.05,50.62,,,,,,,,,,,,,,50.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.56,,,percent of total billed charges,,,,,,,,,50.62,,,percent of total billed charges,,,28.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.62,,,percent of total billed charges,,,,,,,,,,,,,,,50.62,,,percent of total billed charges,,,26.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.05,,,percent of total billed charges,,,50.62,,,percent of total billed charges,,,50.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.55,,,percent of total billed charges,,
MIRABEGRON ER 25 MG TAB,2500032668,CDM,637,RC,469260130,NDC,,,,,,outpatient,facility,25,UN,50.62,50.62,4.05,618.77,,29.56,,,percent of total billed charges,,,9.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,50.62,,,percent of total billed charges,,,44.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,44.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,44.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,50.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,18.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,45.56,,,percent of total billed charges,,,,,,,,,50.62,,,percent of total billed charges,,,34.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.88,,,percent of total billed charges,,,,,,,,,,,,,,,27.33,,,percent of total billed charges,,,27.33,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,50.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.39,,,percent of total billed charges,,,50.62,,,percent of total billed charges,,,50.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.47,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,26.22,,,percent of total billed charges,,,,,,,,,,,,,,,10.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,18.73,,,percent of total billed charges,,,18.73,,,percent of total billed charges,,,50.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,50.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.05,,,percent of total billed charges,,,50.62,,,percent of total billed charges,,,50.62,,,percent of total billed charges,,,,,,,,,,,,,,,50.62,,,percent of total billed charges,,,50.62,,,percent of total billed charges,,,,,,,,,50.62,,,fee schedule,,,47.09,,,percent of total billed charges,,,,,,,,,,,,,,,47.09,,,percent of total billed charges,,,47.09,,,percent of total billed charges,,,47.09,,,percent of total billed charges,,,37.96,,,percent of total billed charges,,,50.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,50.62,,,percent of total billed charges,,,50.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.55,,,percent of total billed charges,,
MIRABEGRON ER 25 MG TAB,2500032668,CDM,637,RC,469260130,NDC,999,EAPG,,,,outpatient,facility,25,UN,50.62,50.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMMUNE GLOB IV 5GM/OCTAGAM,2500032677,CDM,636,RC,J1568,HCPCS,6898284003,NDC,,,,inpatient,facility,100,UN,3205.12,3205.12,256.41,3205.12,,,,,,,,,,,,,,3205.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2884.61,,,percent of total billed charges,,,,,,,,,3205.12,,,percent of total billed charges,,,1774.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.12,,,percent of total billed charges,,,,,,,,,,,,,,,3205.12,,,percent of total billed charges,,,1671.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.41,,,percent of total billed charges,,,3205.12,,,percent of total billed charges,,,3205.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3205.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2250.64,,,percent of total billed charges,,
IMMUNE GLOB IV 5GM/OCTAGAM,2500032677,CDM,636,RC,J1568,HCPCS,6898284003,NDC,,,,outpatient,facility,100,UN,3205.12,3205.12,28.74,3205.12,,1871.79,,,percent of total billed charges,,,,,,,,,3205.12,,,percent of total billed charges,,,56.43,,,fee schedule,,,54.38,,,fee schedule,,,,,,,,,54.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2884.61,,,percent of total billed charges,,,,,,,,,3205.12,,,percent of total billed charges,,,2170.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2461.53,,,percent of total billed charges,,,,,,,,,,,,,,,44.98,,,fee schedule,,,44.98,,,fee schedule,,,,,,,,,618.77,,,per diem,,,3205.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1671.15,,,percent of total billed charges,,,3205.12,,,percent of total billed charges,,,3205.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2435.89,,,percent of total billed charges,,,1214.1,,,percent of total billed charges,,,1659.93,,,percent of total billed charges,,,,,,,,,,,,,,,641.02,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,92.91,,,fee schedule,,,41.43,,,fee schedule,,,,,,,,,,,,,,,256.41,,,percent of total billed charges,,,3205.12,,,percent of total billed charges,,,3205.12,,,percent of total billed charges,,,,,,,,,,,,,,,3205.12,,,percent of total billed charges,,,3205.12,,,percent of total billed charges,,,,,,,,,3205.12,,,fee schedule,,,44.21,,,fee schedule,,,,,,,,,,,,,,,38.87,,,fee schedule,,,51.83,,,fee schedule,,,28.74,,,fee schedule,,,49.54,,,fee schedule,,,3205.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3205.12,,,percent of total billed charges,,,3205.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2250.64,,,percent of total billed charges,,
IMMUNE GLOB IV 5GM/OCTAGAM,2500032677,CDM,636,RC,J1568,HCPCS,6898284003,NDC,943,APC,,outpatient,facility,100,UN,3205.12,3205.12,47.33,1173.07,,,,,,,,50.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,49.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.79,,,fee schedule,,,,,,,,,1173.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,49.3,,,fee schedule,,,,,,,,,,,,,,,49.3,,,fee schedule,,,51.76,,,fee schedule,,,,,,,,,49.3,,,fee schedule,,,49.3,,,fee schedule,,,51.76,,,fee schedule,,,,,,,,,,,,,,,71.48,,,fee schedule,,,,,,,,,,,,,,,49.3,,,fee schedule,,,,,,,,,,,,,,,47.33,,,fee schedule,,,52.75,,,fee schedule,,,51.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.3,,,fee schedule,,,49.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,51.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,61.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,49.3,,,fee schedule,,,49.3,,,fee schedule,,,,,,,,,,,,,,,49.3,,,fee schedule,,,,,,,,,,,,,,,49.3,,,fee schedule,,,50.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49,,,fee schedule,,,49.3,,,fee schedule,,,51.27,,,fee schedule,,,49.3,,,fee schedule,,,,,,,,,49.3,,,fee schedule,,,,,,,,,49.3,,,fee schedule,,,,,,,,
IMMUNE GLOB IV 5GM/OCTAGAM,2500032677,CDM,636,RC,J1568,HCPCS,6898284003,NDC,460,EAPG,,outpatient,facility,100,UN,3205.12,3205.12,1557.16,2282.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2282.8,,,fee schedule,,,1557.16,,,fee schedule,,,2029.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,1557.16,,,fee schedule,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMMUNE GLOB IV 20GM/OCTAGAM,2500032678,CDM,636,RC,J1568,HCPCS,6898285004,NDC,,,,inpatient,facility,200,ML,12327.48,12327.48,986.2,12327.48,,,,,,,,,,,,,,12327.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11094.73,,,percent of total billed charges,,,,,,,,,12327.48,,,percent of total billed charges,,,6824.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11247.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12327.48,,,percent of total billed charges,,,,,,,,,,,,,,,12327.48,,,percent of total billed charges,,,6427.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2465.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,986.2,,,percent of total billed charges,,,12327.48,,,percent of total billed charges,,,12327.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12327.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8656.36,,,percent of total billed charges,,
IMMUNE GLOB IV 20GM/OCTAGAM,2500032678,CDM,636,RC,J1568,HCPCS,6898285004,NDC,,,,outpatient,facility,200,ML,12327.48,12327.48,28.74,12327.48,,7199.25,,,percent of total billed charges,,,,,,,,,12327.48,,,percent of total billed charges,,,56.43,,,fee schedule,,,54.38,,,fee schedule,,,,,,,,,54.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,12327.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,11094.73,,,percent of total billed charges,,,,,,,,,12327.48,,,percent of total billed charges,,,8348.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9467.5,,,percent of total billed charges,,,,,,,,,,,,,,,44.98,,,fee schedule,,,44.98,,,fee schedule,,,,,,,,,618.77,,,per diem,,,12327.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6427.55,,,percent of total billed charges,,,12327.48,,,percent of total billed charges,,,12327.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9368.88,,,percent of total billed charges,,,4669.65,,,percent of total billed charges,,,6384.4,,,percent of total billed charges,,,,,,,,,,,,,,,2465.5,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,92.91,,,fee schedule,,,41.43,,,fee schedule,,,,,,,,,,,,,,,986.2,,,percent of total billed charges,,,12327.48,,,percent of total billed charges,,,12327.48,,,percent of total billed charges,,,,,,,,,,,,,,,12327.48,,,percent of total billed charges,,,12327.48,,,percent of total billed charges,,,,,,,,,12327.48,,,fee schedule,,,44.21,,,fee schedule,,,,,,,,,,,,,,,38.87,,,fee schedule,,,51.83,,,fee schedule,,,28.74,,,fee schedule,,,49.54,,,fee schedule,,,12327.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,12327.48,,,percent of total billed charges,,,12327.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6163.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,8656.36,,,percent of total billed charges,,
IMMUNE GLOB IV 20GM/OCTAGAM,2500032678,CDM,636,RC,J1568,HCPCS,6898285004,NDC,943,APC,,outpatient,facility,200,ML,12327.48,12327.48,47.33,4511.86,,,,,,,,50.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,49.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.79,,,fee schedule,,,,,,,,,4511.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,49.3,,,fee schedule,,,,,,,,,,,,,,,49.3,,,fee schedule,,,51.76,,,fee schedule,,,,,,,,,49.3,,,fee schedule,,,49.3,,,fee schedule,,,51.76,,,fee schedule,,,,,,,,,,,,,,,71.48,,,fee schedule,,,,,,,,,,,,,,,49.3,,,fee schedule,,,,,,,,,,,,,,,47.33,,,fee schedule,,,52.75,,,fee schedule,,,51.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.3,,,fee schedule,,,49.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,51.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,61.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,49.3,,,fee schedule,,,49.3,,,fee schedule,,,,,,,,,,,,,,,49.3,,,fee schedule,,,,,,,,,,,,,,,49.3,,,fee schedule,,,50.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49,,,fee schedule,,,49.3,,,fee schedule,,,51.27,,,fee schedule,,,49.3,,,fee schedule,,,,,,,,,49.3,,,fee schedule,,,,,,,,,49.3,,,fee schedule,,,,,,,,
IMMUNE GLOB IV 20GM/OCTAGAM,2500032678,CDM,636,RC,J1568,HCPCS,6898285004,NDC,460,EAPG,,outpatient,facility,200,ML,12327.48,12327.48,1557.16,2282.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2282.8,,,fee schedule,,,1557.16,,,fee schedule,,,2029.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,1557.16,,,fee schedule,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MENTHOL/ZINC OXIDE 71G OINT,2500032680,CDM,637,RC,799000103,NDC,,,,,,inpatient,facility,71,UN,10.5,10.5,0.84,10.5,,,,,,,,,,,,,,10.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.45,,,percent of total billed charges,,,,,,,,,10.5,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.5,,,percent of total billed charges,,,,,,,,,,,,,,,10.5,,,percent of total billed charges,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,10.5,,,percent of total billed charges,,,10.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.37,,,percent of total billed charges,,
MENTHOL/ZINC OXIDE 71G OINT,2500032680,CDM,637,RC,799000103,NDC,,,,,,outpatient,facility,71,UN,10.5,10.5,0.84,618.77,,6.13,,,percent of total billed charges,,,2.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.5,,,percent of total billed charges,,,9.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,9.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,9.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.45,,,percent of total billed charges,,,,,,,,,10.5,,,percent of total billed charges,,,7.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.06,,,percent of total billed charges,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,10.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,10.5,,,percent of total billed charges,,,10.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,2.1,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.88,,,percent of total billed charges,,,3.88,,,percent of total billed charges,,,10.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.84,,,percent of total billed charges,,,10.5,,,percent of total billed charges,,,10.5,,,percent of total billed charges,,,,,,,,,,,,,,,10.5,,,percent of total billed charges,,,10.5,,,percent of total billed charges,,,,,,,,,10.5,,,fee schedule,,,9.77,,,percent of total billed charges,,,,,,,,,,,,,,,9.77,,,percent of total billed charges,,,9.77,,,percent of total billed charges,,,9.77,,,percent of total billed charges,,,7.88,,,percent of total billed charges,,,10.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.5,,,percent of total billed charges,,,10.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.37,,,percent of total billed charges,,
MENTHOL/ZINC OXIDE 71G OINT,2500032680,CDM,637,RC,799000103,NDC,999,EAPG,,,,outpatient,facility,71,UN,10.5,10.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BIKTARVY TAB,2500032681,CDM,637,RC,6195825011,NDC,,,,,,inpatient,facility,1,UN,437.94,437.94,35.04,437.94,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,394.15,,,percent of total billed charges,,,,,,,,,437.94,,,percent of total billed charges,,,242.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,399.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,228.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.04,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.52,,,percent of total billed charges,,
BIKTARVY TAB,2500032681,CDM,637,RC,6195825011,NDC,,,,,,outpatient,facility,1,UN,437.94,437.94,35.04,618.77,,255.76,,,percent of total billed charges,,,85.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,437.94,,,percent of total billed charges,,,385.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,385.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,385.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,160.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,394.15,,,percent of total billed charges,,,,,,,,,437.94,,,percent of total billed charges,,,296.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.34,,,percent of total billed charges,,,,,,,,,,,,,,,236.49,,,percent of total billed charges,,,236.49,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,228.34,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.83,,,percent of total billed charges,,,165.89,,,percent of total billed charges,,,226.81,,,percent of total billed charges,,,,,,,,,,,,,,,87.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,162.04,,,percent of total billed charges,,,162.04,,,percent of total billed charges,,,437.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,437.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.04,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,437.94,,,fee schedule,,,407.37,,,percent of total billed charges,,,,,,,,,,,,,,,407.37,,,percent of total billed charges,,,407.37,,,percent of total billed charges,,,407.37,,,percent of total billed charges,,,328.45,,,percent of total billed charges,,,437.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,307.52,,,percent of total billed charges,,
BIKTARVY TAB,2500032681,CDM,637,RC,6195825011,NDC,999,EAPG,,,,outpatient,facility,1,UN,437.94,437.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLYCERIN ADULT SUPP,2500032707,CDM,637,RC,5898041012,NDC,,,,,,inpatient,facility,1,UN,0.66,0.66,0.05,0.66,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,
GLYCERIN ADULT SUPP,2500032707,CDM,637,RC,5898041012,NDC,,,,,,outpatient,facility,1,UN,0.66,0.66,0.05,618.77,,0.39,,,percent of total billed charges,,,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,0.66,,,percent of total billed charges,,,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,0.59,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,0.66,,,fee schedule,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,0.46,,,percent of total billed charges,,
GLYCERIN ADULT SUPP,2500032707,CDM,637,RC,5898041012,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.66,0.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SEVELAMER CARB PWD 0.8 GM PKT,2500032713,CDM,637,RC,4359847890,NDC,,,,,,inpatient,facility,800,UN,60.35,60.35,4.83,60.35,,,,,,,,,,,,,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.32,,,percent of total billed charges,,,,,,,,,60.35,,,percent of total billed charges,,,33.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,60.35,,,percent of total billed charges,,,31.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.83,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.38,,,percent of total billed charges,,
SEVELAMER CARB PWD 0.8 GM PKT,2500032713,CDM,637,RC,4359847890,NDC,,,,,,outpatient,facility,800,UN,60.35,60.35,4.83,618.77,,35.24,,,percent of total billed charges,,,11.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,60.35,,,percent of total billed charges,,,53.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,53.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,53.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,22.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,54.32,,,percent of total billed charges,,,,,,,,,60.35,,,percent of total billed charges,,,40.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.35,,,percent of total billed charges,,,,,,,,,,,,,,,32.59,,,percent of total billed charges,,,32.59,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.47,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.87,,,percent of total billed charges,,,22.86,,,percent of total billed charges,,,31.26,,,percent of total billed charges,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,22.33,,,percent of total billed charges,,,22.33,,,percent of total billed charges,,,60.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,60.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.83,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,60.35,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,,,,,,,60.35,,,fee schedule,,,56.14,,,percent of total billed charges,,,,,,,,,,,,,,,56.14,,,percent of total billed charges,,,56.14,,,percent of total billed charges,,,56.14,,,percent of total billed charges,,,45.26,,,percent of total billed charges,,,60.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,60.35,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,42.38,,,percent of total billed charges,,
SEVELAMER CARB PWD 0.8 GM PKT,2500032713,CDM,637,RC,4359847890,NDC,999,EAPG,,,,outpatient,facility,800,UN,60.35,60.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOL IRRIG NACL 100ML,2500032728,CDM,258,RC,8080102000,NDC,,,,,,inpatient,facility,100,UN,2.38,2.38,0.19,2.38,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,2.38,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,
SOL IRRIG NACL 100ML,2500032728,CDM,258,RC,8080102000,NDC,,,,,,outpatient,facility,100,UN,2.38,2.38,0.19,618.77,,1.39,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2.38,,,percent of total billed charges,,,2.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,2.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,2.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,0.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2.14,,,percent of total billed charges,,,,,,,,,2.38,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,0.9,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,2.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,2.38,,,fee schedule,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,2.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1.67,,,percent of total billed charges,,
SOL IRRIG NACL 100ML,2500032728,CDM,258,RC,8080102000,NDC,999,EAPG,,,,outpatient,facility,100,UN,2.38,2.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA EPBX 3000 U,2500032735,CDM,636,RC,Q5106,HCPCS,69130610,NDC,,,,inpatient,facility,1,UN,109.19,109.19,8.74,109.19,,,,,,,,,,,,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.27,,,percent of total billed charges,,,,,,,,,109.19,,,percent of total billed charges,,,60.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,109.19,,,percent of total billed charges,,,56.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.74,,,percent of total billed charges,,,109.19,,,percent of total billed charges,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.67,,,percent of total billed charges,,
EPOETIN ALFA EPBX 3000 U,2500032735,CDM,636,RC,Q5106,HCPCS,69130610,NDC,,,,outpatient,facility,1,UN,109.19,109.19,5.55,618.77,,63.77,,,percent of total billed charges,,,,,,,,,109.19,,,percent of total billed charges,,,8.06,,,fee schedule,,,7.77,,,fee schedule,,,,,,,,,7.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,98.27,,,percent of total billed charges,,,,,,,,,109.19,,,percent of total billed charges,,,73.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,,percent of total billed charges,,,,,,,,,,,,,,,7.82,,,fee schedule,,,7.82,,,fee schedule,,,,,,,,,618.77,,,per diem,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.93,,,percent of total billed charges,,,109.19,,,percent of total billed charges,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.98,,,percent of total billed charges,,,41.36,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,,,,,,,,,,,,,21.84,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,17.94,,,fee schedule,,,8,,,fee schedule,,,,,,,,,,,,,,,8.74,,,percent of total billed charges,,,109.19,,,percent of total billed charges,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,109.19,,,percent of total billed charges,,,109.19,,,percent of total billed charges,,,,,,,,,109.19,,,fee schedule,,,8.54,,,fee schedule,,,,,,,,,,,,,,,7.51,,,fee schedule,,,10.01,,,fee schedule,,,5.55,,,fee schedule,,,7.07,,,fee schedule,,,109.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,109.19,,,percent of total billed charges,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,76.67,,,percent of total billed charges,,
EPOETIN ALFA EPBX 3000 U,2500032735,CDM,636,RC,Q5106,HCPCS,69130610,NDC,9097,APC,,outpatient,facility,1,UN,109.19,109.19,7.17,39.96,,,,,,,,7.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.54,,,fee schedule,,,,,,,,,39.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,10.83,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.17,,,fee schedule,,,7.99,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.62,,,fee schedule,,,7.47,,,fee schedule,,,7.77,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,,,,,,
EPOETIN ALFA EPBX 3000 U,2500032735,CDM,636,RC,Q5106,HCPCS,69130610,NDC,438,EAPG,,outpatient,facility,1,UN,109.19,109.19,323.15,473.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.74,,,fee schedule,,,323.15,,,fee schedule,,,421.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA EPBX 10000 U,2500032736,CDM,636,RC,Q5106,HCPCS,69130810,NDC,,,,inpatient,facility,1,UN,363.99,363.99,29.12,363.99,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,327.59,,,percent of total billed charges,,,,,,,,,363.99,,,percent of total billed charges,,,201.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,189.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.12,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.59,,,percent of total billed charges,,
EPOETIN ALFA EPBX 10000 U,2500032736,CDM,636,RC,Q5106,HCPCS,69130810,NDC,,,,outpatient,facility,1,UN,363.99,363.99,5.55,618.77,,212.57,,,percent of total billed charges,,,,,,,,,363.99,,,percent of total billed charges,,,8.06,,,fee schedule,,,7.77,,,fee schedule,,,,,,,,,7.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,327.59,,,percent of total billed charges,,,,,,,,,363.99,,,percent of total billed charges,,,246.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.54,,,percent of total billed charges,,,,,,,,,,,,,,,7.82,,,fee schedule,,,7.82,,,fee schedule,,,,,,,,,618.77,,,per diem,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,189.78,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.63,,,percent of total billed charges,,,137.88,,,percent of total billed charges,,,188.51,,,percent of total billed charges,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,17.94,,,fee schedule,,,8,,,fee schedule,,,,,,,,,,,,,,,29.12,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,363.99,,,fee schedule,,,8.54,,,fee schedule,,,,,,,,,,,,,,,7.51,,,fee schedule,,,10.01,,,fee schedule,,,5.55,,,fee schedule,,,7.07,,,fee schedule,,,363.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,255.59,,,percent of total billed charges,,
EPOETIN ALFA EPBX 10000 U,2500032736,CDM,636,RC,Q5106,HCPCS,69130810,NDC,9097,APC,,outpatient,facility,1,UN,363.99,363.99,7.17,133.22,,,,,,,,7.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.54,,,fee schedule,,,,,,,,,133.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,10.83,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.17,,,fee schedule,,,7.99,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.62,,,fee schedule,,,7.47,,,fee schedule,,,7.77,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,,,,,,
EPOETIN ALFA EPBX 10000 U,2500032736,CDM,636,RC,Q5106,HCPCS,69130810,NDC,438,EAPG,,outpatient,facility,1,UN,363.99,363.99,323.15,473.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.74,,,fee schedule,,,323.15,,,fee schedule,,,421.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA EPBX 4000 U,2500032737,CDM,636,RC,Q5106,HCPCS,69130710,NDC,,,,inpatient,facility,1,UN,145.6,145.6,11.65,145.6,,,,,,,,,,,,,,145.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.04,,,percent of total billed charges,,,,,,,,,145.6,,,percent of total billed charges,,,80.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.6,,,percent of total billed charges,,,,,,,,,,,,,,,145.6,,,percent of total billed charges,,,75.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.65,,,percent of total billed charges,,,145.6,,,percent of total billed charges,,,145.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,145.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.24,,,percent of total billed charges,,
EPOETIN ALFA EPBX 4000 U,2500032737,CDM,636,RC,Q5106,HCPCS,69130710,NDC,,,,outpatient,facility,1,UN,145.6,145.6,5.55,618.77,,85.03,,,percent of total billed charges,,,,,,,,,145.6,,,percent of total billed charges,,,8.06,,,fee schedule,,,7.77,,,fee schedule,,,,,,,,,7.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,131.04,,,percent of total billed charges,,,,,,,,,145.6,,,percent of total billed charges,,,98.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.82,,,percent of total billed charges,,,,,,,,,,,,,,,7.82,,,fee schedule,,,7.82,,,fee schedule,,,,,,,,,618.77,,,per diem,,,145.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,75.92,,,percent of total billed charges,,,145.6,,,percent of total billed charges,,,145.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.66,,,percent of total billed charges,,,55.15,,,percent of total billed charges,,,75.41,,,percent of total billed charges,,,,,,,,,,,,,,,29.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,17.94,,,fee schedule,,,8,,,fee schedule,,,,,,,,,,,,,,,11.65,,,percent of total billed charges,,,145.6,,,percent of total billed charges,,,145.6,,,percent of total billed charges,,,,,,,,,,,,,,,145.6,,,percent of total billed charges,,,145.6,,,percent of total billed charges,,,,,,,,,145.6,,,fee schedule,,,8.54,,,fee schedule,,,,,,,,,,,,,,,7.51,,,fee schedule,,,10.01,,,fee schedule,,,5.55,,,fee schedule,,,7.07,,,fee schedule,,,145.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,145.6,,,percent of total billed charges,,,145.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,102.24,,,percent of total billed charges,,
EPOETIN ALFA EPBX 4000 U,2500032737,CDM,636,RC,Q5106,HCPCS,69130710,NDC,9097,APC,,outpatient,facility,1,UN,145.6,145.6,7.17,53.29,,,,,,,,7.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.54,,,fee schedule,,,,,,,,,53.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,10.83,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.17,,,fee schedule,,,7.99,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.62,,,fee schedule,,,7.47,,,fee schedule,,,7.77,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,,,,,,
EPOETIN ALFA EPBX 4000 U,2500032737,CDM,636,RC,Q5106,HCPCS,69130710,NDC,438,EAPG,,outpatient,facility,1,UN,145.6,145.6,323.15,473.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.74,,,fee schedule,,,323.15,,,fee schedule,,,421.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA EPBX 2000 U,2500032738,CDM,636,RC,Q5106,HCPCS,69130510,NDC,,,,inpatient,facility,1,UN,72.8,72.8,5.82,72.8,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.52,,,percent of total billed charges,,,,,,,,,72.8,,,percent of total billed charges,,,40.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,37.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.82,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.12,,,percent of total billed charges,,
EPOETIN ALFA EPBX 2000 U,2500032738,CDM,636,RC,Q5106,HCPCS,69130510,NDC,,,,outpatient,facility,1,UN,72.8,72.8,5.55,618.77,,42.52,,,percent of total billed charges,,,,,,,,,72.8,,,percent of total billed charges,,,8.06,,,fee schedule,,,7.77,,,fee schedule,,,,,,,,,7.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,65.52,,,percent of total billed charges,,,,,,,,,72.8,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.91,,,percent of total billed charges,,,,,,,,,,,,,,,7.82,,,fee schedule,,,7.82,,,fee schedule,,,,,,,,,618.77,,,per diem,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.96,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.33,,,percent of total billed charges,,,27.58,,,percent of total billed charges,,,37.7,,,percent of total billed charges,,,,,,,,,,,,,,,14.56,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,17.94,,,fee schedule,,,8,,,fee schedule,,,,,,,,,,,,,,,5.82,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,72.8,,,fee schedule,,,8.54,,,fee schedule,,,,,,,,,,,,,,,7.51,,,fee schedule,,,10.01,,,fee schedule,,,5.55,,,fee schedule,,,7.07,,,fee schedule,,,72.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,72.8,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,51.12,,,percent of total billed charges,,
EPOETIN ALFA EPBX 2000 U,2500032738,CDM,636,RC,Q5106,HCPCS,69130510,NDC,9097,APC,,outpatient,facility,1,UN,72.8,72.8,7.17,26.64,,,,,,,,7.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.54,,,fee schedule,,,,,,,,,26.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,10.83,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.17,,,fee schedule,,,7.99,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.62,,,fee schedule,,,7.47,,,fee schedule,,,7.77,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,,,,,,
EPOETIN ALFA EPBX 2000 U,2500032738,CDM,636,RC,Q5106,HCPCS,69130510,NDC,438,EAPG,,outpatient,facility,1,UN,72.8,72.8,323.15,473.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.74,,,fee schedule,,,323.15,,,fee schedule,,,421.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,323.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LABETALOL HCL 200 MG/40ML INJ,2500032744,CDM,250,RC,J3490,HCPCS,4778158656,NDC,,,,inpatient,facility,40,UN,90.75,90.75,7.26,90.75,,,,,,,,,,,,,,90.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.67,,,percent of total billed charges,,,,,,,,,90.75,,,percent of total billed charges,,,50.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.75,,,percent of total billed charges,,,,,,,,,,,,,,,90.75,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.26,,,percent of total billed charges,,,90.75,,,percent of total billed charges,,,90.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.72,,,percent of total billed charges,,
LABETALOL HCL 200 MG/40ML INJ,2500032744,CDM,250,RC,J3490,HCPCS,4778158656,NDC,,,,outpatient,facility,40,UN,90.75,90.75,1.2,618.77,,53,,,percent of total billed charges,,,17.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,90.75,,,percent of total billed charges,,,79.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,79.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,79.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,90.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,33.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,81.67,,,percent of total billed charges,,,,,,,,,90.75,,,percent of total billed charges,,,61.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.7,,,percent of total billed charges,,,,,,,,,,,,,,,90.75,,,percent of total billed charges,,,90.75,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,90.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.32,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.97,,,percent of total billed charges,,,34.38,,,percent of total billed charges,,,47,,,percent of total billed charges,,,,,,,,,,,,,,,18.15,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,90.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,90.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.26,,,percent of total billed charges,,,90.75,,,percent of total billed charges,,,90.75,,,percent of total billed charges,,,,,,,,,,,,,,,90.75,,,percent of total billed charges,,,90.75,,,percent of total billed charges,,,,,,,,,90.75,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,68.06,,,percent of total billed charges,,,90.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,90.75,,,percent of total billed charges,,,90.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,63.72,,,percent of total billed charges,,
LABETALOL HCL 200 MG/40ML INJ,2500032744,CDM,250,RC,J3490,HCPCS,4778158656,NDC,435,EAPG,,outpatient,facility,40,UN,90.75,90.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA EPBX 10000U ESRD,2500032750,CDM,635,RC,Q5105,HCPCS,69130810,NDC,,,,inpatient,facility,1,UN,363.99,363.99,29.12,363.99,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,327.59,,,percent of total billed charges,,,,,,,,,363.99,,,percent of total billed charges,,,201.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,189.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.12,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.59,,,percent of total billed charges,,
EPOETIN ALFA EPBX 10000U ESRD,2500032750,CDM,635,RC,Q5105,HCPCS,69130810,NDC,,,,outpatient,facility,1,UN,363.99,363.99,0.7,618.77,,212.57,,,percent of total billed charges,,,,,,,,,363.99,,,percent of total billed charges,,,0.8,,,fee schedule,,,0.77,,,fee schedule,,,,,,,,,0.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,327.59,,,percent of total billed charges,,,,,,,,,363.99,,,percent of total billed charges,,,246.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,fee schedule,,,0.78,,,fee schedule,,,,,,,,,618.77,,,per diem,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,189.78,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.63,,,percent of total billed charges,,,137.88,,,percent of total billed charges,,,188.51,,,percent of total billed charges,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,29.12,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,363.99,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.7,,,fee schedule,,,363.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,255.59,,,percent of total billed charges,,
EPOETIN ALFA EPBX 10000U ESRD,2500032750,CDM,635,RC,Q5105,HCPCS,69130810,NDC,9096,APC,,outpatient,facility,1,UN,363.99,363.99,0.72,133.22,,,,,,,,0.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,fee schedule,,,,,,,,,133.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.75,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,,,,,,,1.09,,,fee schedule,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.72,,,fee schedule,,,0.8,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.75,,,fee schedule,,,0.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,fee schedule,,,0.75,,,fee schedule,,,0.78,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,,,,,,
EPOETIN ALFA EPBX 10000U ESRD,2500032750,CDM,635,RC,Q5105,HCPCS,69130810,NDC,436,EAPG,,outpatient,facility,1,UN,363.99,363.99,126.95,186.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.11,,,fee schedule,,,126.95,,,fee schedule,,,165.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUANFACINE 1 MG ER TAB,2500032753,CDM,637,RC,6050539271,NDC,,,,,,inpatient,facility,1,UN,34.61,34.61,2.77,34.61,,,,,,,,,,,,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.15,,,percent of total billed charges,,,,,,,,,34.61,,,percent of total billed charges,,,19.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,34.61,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.3,,,percent of total billed charges,,
GUANFACINE 1 MG ER TAB,2500032753,CDM,637,RC,6050539271,NDC,,,,,,outpatient,facility,1,UN,34.61,34.61,2.77,618.77,,20.21,,,percent of total billed charges,,,6.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,34.61,,,percent of total billed charges,,,30.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,30.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,30.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,12.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,31.15,,,percent of total billed charges,,,,,,,,,34.61,,,percent of total billed charges,,,23.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.58,,,percent of total billed charges,,,,,,,,,,,,,,,18.69,,,percent of total billed charges,,,18.69,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.3,,,percent of total billed charges,,,13.11,,,percent of total billed charges,,,17.92,,,percent of total billed charges,,,,,,,,,,,,,,,6.92,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,12.81,,,percent of total billed charges,,,12.81,,,percent of total billed charges,,,34.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,34.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,34.61,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,,,,,,,34.61,,,fee schedule,,,32.19,,,percent of total billed charges,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,32.19,,,percent of total billed charges,,,32.19,,,percent of total billed charges,,,25.96,,,percent of total billed charges,,,34.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,34.61,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,24.3,,,percent of total billed charges,,
GUANFACINE 1 MG ER TAB,2500032753,CDM,637,RC,6050539271,NDC,999,EAPG,,,,outpatient,facility,1,UN,34.61,34.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IODINE/POTASSIUM IODIDE 14ML,2500032762,CDM,637,RC,4843323015,NDC,,,,,,inpatient,facility,14,UN,106.43,106.43,8.51,106.43,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.79,,,percent of total billed charges,,,,,,,,,106.43,,,percent of total billed charges,,,58.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,55.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.74,,,percent of total billed charges,,
IODINE/POTASSIUM IODIDE 14ML,2500032762,CDM,637,RC,4843323015,NDC,,,,,,outpatient,facility,14,UN,106.43,106.43,8.51,618.77,,62.16,,,percent of total billed charges,,,20.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,106.43,,,percent of total billed charges,,,93.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,93.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,93.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,38.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,95.79,,,percent of total billed charges,,,,,,,,,106.43,,,percent of total billed charges,,,72.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.74,,,percent of total billed charges,,,,,,,,,,,,,,,57.47,,,percent of total billed charges,,,57.47,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.49,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.89,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,55.12,,,percent of total billed charges,,,,,,,,,,,,,,,21.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,39.38,,,percent of total billed charges,,,39.38,,,percent of total billed charges,,,106.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,106.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.51,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,,,,,,,106.43,,,fee schedule,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,79.82,,,percent of total billed charges,,,106.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,106.43,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,74.74,,,percent of total billed charges,,
IODINE/POTASSIUM IODIDE 14ML,2500032762,CDM,637,RC,4843323015,NDC,999,EAPG,,,,outpatient,facility,14,UN,106.43,106.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ERAVACYCLINE 50 MG INJ,2500032769,CDM,636,RC,J0122,HCPCS,7177305012,NDC,,,,inpatient,facility,50,UN,202.95,202.95,16.24,202.95,,,,,,,,,,,,,,202.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.66,,,percent of total billed charges,,,,,,,,,202.95,,,percent of total billed charges,,,112.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.95,,,percent of total billed charges,,,,,,,,,,,,,,,202.95,,,percent of total billed charges,,,105.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.24,,,percent of total billed charges,,,202.95,,,percent of total billed charges,,,202.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,202.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.51,,,percent of total billed charges,,
ERAVACYCLINE 50 MG INJ,2500032769,CDM,636,RC,J0122,HCPCS,7177305012,NDC,,,,outpatient,facility,50,UN,202.95,202.95,1.13,618.77,,118.52,,,percent of total billed charges,,,39.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,202.95,,,percent of total billed charges,,,1.43,,,fee schedule,,,1.38,,,fee schedule,,,,,,,,,1.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,202.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,74.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,182.66,,,percent of total billed charges,,,,,,,,,202.95,,,percent of total billed charges,,,137.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.13,,,fee schedule,,,1.13,,,fee schedule,,,,,,,,,618.77,,,per diem,,,202.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,105.82,,,percent of total billed charges,,,202.95,,,percent of total billed charges,,,202.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.24,,,percent of total billed charges,,,76.88,,,percent of total billed charges,,,105.11,,,percent of total billed charges,,,,,,,,,,,,,,,40.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,202.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,202.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.24,,,percent of total billed charges,,,202.95,,,percent of total billed charges,,,202.95,,,percent of total billed charges,,,,,,,,,,,,,,,202.95,,,percent of total billed charges,,,202.95,,,percent of total billed charges,,,,,,,,,202.95,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.25,,,fee schedule,,,202.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,202.95,,,percent of total billed charges,,,202.95,,,percent of total billed charges,,,1.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,142.51,,,percent of total billed charges,,
ERAVACYCLINE 50 MG INJ,2500032769,CDM,636,RC,J0122,HCPCS,7177305012,NDC,436,EAPG,,outpatient,facility,50,UN,202.95,202.95,126.95,186.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.11,,,fee schedule,,,126.95,,,fee schedule,,,165.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,126.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NALDEMEDINE 0.2 MG TAB,2500032786,CDM,637,RC,5938504130,NDC,,,,,,inpatient,facility,0.2,UN,61.08,61.08,4.89,61.08,,,,,,,,,,,,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.97,,,percent of total billed charges,,,,,,,,,61.08,,,percent of total billed charges,,,33.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,61.08,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.89,,,percent of total billed charges,,
NALDEMEDINE 0.2 MG TAB,2500032786,CDM,637,RC,5938504130,NDC,,,,,,outpatient,facility,0.2,UN,61.08,61.08,4.89,618.77,,35.67,,,percent of total billed charges,,,11.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,61.08,,,percent of total billed charges,,,53.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,53.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,53.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,22.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,54.97,,,percent of total billed charges,,,,,,,,,61.08,,,percent of total billed charges,,,41.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.91,,,percent of total billed charges,,,,,,,,,,,,,,,32.98,,,percent of total billed charges,,,32.98,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.42,,,percent of total billed charges,,,23.14,,,percent of total billed charges,,,31.63,,,percent of total billed charges,,,,,,,,,,,,,,,12.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,22.6,,,percent of total billed charges,,,22.6,,,percent of total billed charges,,,61.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,61.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.89,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,61.08,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,,,,,,,61.08,,,fee schedule,,,56.82,,,percent of total billed charges,,,,,,,,,,,,,,,56.82,,,percent of total billed charges,,,56.82,,,percent of total billed charges,,,56.82,,,percent of total billed charges,,,45.81,,,percent of total billed charges,,,61.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,61.08,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,42.89,,,percent of total billed charges,,
NALDEMEDINE 0.2 MG TAB,2500032786,CDM,637,RC,5938504130,NDC,999,EAPG,,,,outpatient,facility,0.2,UN,61.08,61.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIG-HT FOR IM/SQ,2500032806,CDM,636,RC,90376,CPT,4928119020,NDC,,,,inpatient,facility,2,ML,2986.92,2986.92,238.95,2986.92,,,,,,,,,,,,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2688.23,,,percent of total billed charges,,,,,,,,,2986.92,,,percent of total billed charges,,,1653.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2725.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,2986.92,,,percent of total billed charges,,,1557.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,597.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.95,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2097.42,,,percent of total billed charges,,
RIG-HT FOR IM/SQ,2500032806,CDM,636,RC,90376,CPT,4928119020,NDC,,,,outpatient,facility,2,ML,2986.92,2986.92,222.31,2986.92,,1744.36,,,percent of total billed charges,,,,,,,,,2986.92,,,percent of total billed charges,,,609.83,,,fee schedule,,,587.64,,,fee schedule,,,,,,,,,587.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2688.23,,,percent of total billed charges,,,,,,,,,2986.92,,,percent of total billed charges,,,2022.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2293.95,,,percent of total billed charges,,,,,,,,,,,,,,,479.72,,,fee schedule,,,479.72,,,fee schedule,,,,,,,,,618.77,,,per diem,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1557.38,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2270.06,,,percent of total billed charges,,,1131.45,,,percent of total billed charges,,,1546.93,,,percent of total billed charges,,,,,,,,,,,,,,,597.38,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,718.86,,,fee schedule,,,320.51,,,fee schedule,,,,,,,,,,,,,,,238.95,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,2986.92,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,,,,,,,2986.92,,,fee schedule,,,342.01,,,fee schedule,,,,,,,,,,,,,,,300.74,,,fee schedule,,,400.99,,,fee schedule,,,222.31,,,fee schedule,,,497.83,,,fee schedule,,,2986.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2986.92,,,percent of total billed charges,,,2986.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1493.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,service not payable
RIG-HT FOR IM/SQ,2500032806,CDM,636,RC,90376,CPT,4928119020,NDC,9134,APC,,outpatient,facility,2,ML,2986.92,2986.92,333.43,1093.21,,,,,,,,357.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,347.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.79,,,fee schedule,,,,,,,,,1093.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,347.32,,,fee schedule,,,,,,,,,,,,,,,347.32,,,fee schedule,,,364.69,,,fee schedule,,,,,,,,,347.32,,,fee schedule,,,347.32,,,fee schedule,,,364.69,,,fee schedule,,,,,,,,,,,,,,,503.61,,,fee schedule,,,,,,,,,,,,,,,347.32,,,fee schedule,,,,,,,,,,,,,,,333.43,,,fee schedule,,,371.63,,,fee schedule,,,364.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,347.32,,,fee schedule,,,347.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,361.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,434.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,434.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,347.32,,,fee schedule,,,347.32,,,fee schedule,,,,,,,,,,,,,,,347.32,,,fee schedule,,,,,,,,,,,,,,,347.32,,,fee schedule,,,357.74,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,479.72,,,fee schedule,,,347.32,,,fee schedule,,,361.21,,,fee schedule,,,347.32,,,fee schedule,,,,,,,,,347.32,,,fee schedule,,,,,,,,,347.32,,,fee schedule,,,,,,,,
RIG-HT FOR IM/SQ,2500032806,CDM,636,RC,90376,CPT,4928119020,NDC,460,EAPG,,outpatient,facility,2,ML,2986.92,2986.92,1557.16,2282.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2282.8,,,fee schedule,,,1557.16,,,fee schedule,,,2029.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,1557.16,,,fee schedule,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1557.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INFLUENZA VX FLUZONE 0.5ML PF,2500032808,CDM,636,RC,90686,CPT,,,,,,inpatient,facility,1,UN,62.73,62.73,5.02,62.73,,,,,,,,,,,,,,62.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.46,,,percent of total billed charges,,,,,,,,,62.73,,,percent of total billed charges,,,34.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.73,,,percent of total billed charges,,,,,,,,,,,,,,,62.73,,,percent of total billed charges,,,32.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,62.73,,,percent of total billed charges,,,62.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.05,,,percent of total billed charges,,
INFLUENZA VX FLUZONE 0.5ML PF,2500032808,CDM,636,RC,90686,CPT,,,,,,outpatient,facility,1,UN,62.73,62.73,5.02,618.77,,36.63,,,percent of total billed charges,,,18.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,62.73,,,percent of total billed charges,,,26.42,,,fee schedule,,,25.46,,,fee schedule,,,17.83,,,fee schedule,,,25.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,62.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.01,,,fee schedule,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,17.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,56.46,,,percent of total billed charges,,,17.83,,,fee schedule,,,62.73,,,percent of total billed charges,,,42.48,,,percent of total billed charges,,,18.72,,,fee schedule,,,18.72,,,fee schedule,,,,,,,,,17.83,,,fee schedule,,,17.83,,,fee schedule,,,18.72,,,fee schedule,,,48.18,,,percent of total billed charges,,,,,,,,,25.85,,,fee schedule,,,22.35,,,fee schedule,,,22.35,,,fee schedule,,,18.37,,,fee schedule,,,618.77,,,per diem,,,62.73,,,percent of total billed charges,,,17.21,,,fee schedule,,,19.08,,,fee schedule,,,19.1,,,fee schedule,,,32.71,,,percent of total billed charges,,,62.73,,,percent of total billed charges,,,62.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.83,,,fee schedule,,,17.83,,,fee schedule,,,47.67,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,32.49,,,percent of total billed charges,,,,,,,,,18.92,,,fee schedule,,,12.55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,47.49,,,fee schedule,,,21.18,,,fee schedule,,,22.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.02,,,percent of total billed charges,,,62.73,,,percent of total billed charges,,,62.73,,,percent of total billed charges,,,17.83,,,fee schedule,,,17.83,,,fee schedule,,,62.73,,,percent of total billed charges,,,62.73,,,percent of total billed charges,,,17.83,,,fee schedule,,,62.73,,,fee schedule,,,22.6,,,fee schedule,,,17.83,,,fee schedule,,,18.36,,,fee schedule,,,19.87,,,fee schedule,,,26.49,,,fee schedule,,,14.69,,,fee schedule,,,23.19,,,fee schedule,,,62.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,62.73,,,percent of total billed charges,,,62.73,,,percent of total billed charges,,,20.75,,,fee schedule,,,17.83,,,fee schedule,,,19.01,,,fee schedule,,,17.83,,,fee schedule,,,17.83,,,fee schedule,,,18.19,,,fee schedule,,,31.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,18.19,,,fee schedule,,,44.05,,,percent of total billed charges,,
INFLUENZA VX FLUZONE 0.5ML PF,2500032808,CDM,636,RC,90686,CPT,414,EAPG,,,,outpatient,facility,1,UN,62.73,62.73,23.83,34.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.93,,,fee schedule,,,23.83,,,fee schedule,,,31.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALOGLIPTIN 25 MG TAB,2500032904,CDM,637,RC,4580215065,NDC,,,,,,inpatient,facility,25,UN,25.74,25.74,2.06,25.74,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.17,,,percent of total billed charges,,,,,,,,,25.74,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,13.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.07,,,percent of total billed charges,,
ALOGLIPTIN 25 MG TAB,2500032904,CDM,637,RC,4580215065,NDC,,,,,,outpatient,facility,25,UN,25.74,25.74,2.06,618.77,,15.03,,,percent of total billed charges,,,5.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,25.74,,,percent of total billed charges,,,22.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,22.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,22.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,23.17,,,percent of total billed charges,,,,,,,,,25.74,,,percent of total billed charges,,,17.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,13.9,,,percent of total billed charges,,,13.9,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.42,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.56,,,percent of total billed charges,,,9.75,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,9.52,,,percent of total billed charges,,,9.52,,,percent of total billed charges,,,25.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.06,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,,,,,,,25.74,,,fee schedule,,,23.94,,,percent of total billed charges,,,,,,,,,,,,,,,23.94,,,percent of total billed charges,,,23.94,,,percent of total billed charges,,,23.94,,,percent of total billed charges,,,19.3,,,percent of total billed charges,,,25.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,25.74,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,18.07,,,percent of total billed charges,,
ALOGLIPTIN 25 MG TAB,2500032904,CDM,637,RC,4580215065,NDC,999,EAPG,,,,outpatient,facility,25,UN,25.74,25.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL 2MCG/BUP 0.125 250ML,2500032911,CDM,636,RC,,,,,,,,inpatient,facility,250,UN,220.11,220.11,17.61,220.11,,,,,,,,,,,,,,220.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.1,,,percent of total billed charges,,,,,,,,,220.11,,,percent of total billed charges,,,121.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.11,,,percent of total billed charges,,,,,,,,,,,,,,,220.11,,,percent of total billed charges,,,114.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.61,,,percent of total billed charges,,,220.11,,,percent of total billed charges,,,220.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,220.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.56,,,percent of total billed charges,,
FENTANYL 2MCG/BUP 0.125 250ML,2500032911,CDM,636,RC,,,,,,,,outpatient,facility,250,UN,220.11,220.11,17.61,618.77,,128.54,,,percent of total billed charges,,,42.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,220.11,,,percent of total billed charges,,,193.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,193.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,193.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,220.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,80.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,198.1,,,percent of total billed charges,,,,,,,,,220.11,,,percent of total billed charges,,,149.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.04,,,percent of total billed charges,,,,,,,,,,,,,,,118.86,,,percent of total billed charges,,,118.86,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,220.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.77,,,percent of total billed charges,,,220.11,,,percent of total billed charges,,,220.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.28,,,percent of total billed charges,,,83.38,,,percent of total billed charges,,,113.99,,,percent of total billed charges,,,,,,,,,,,,,,,44.02,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,88.04,,,percent of total billed charges,,,88.04,,,percent of total billed charges,,,220.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,220.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.61,,,percent of total billed charges,,,220.11,,,percent of total billed charges,,,220.11,,,percent of total billed charges,,,,,,,,,,,,,,,220.11,,,percent of total billed charges,,,220.11,,,percent of total billed charges,,,,,,,,,220.11,,,fee schedule,,,88.04,,,percent of total billed charges,,,,,,,,,,,,,,,88.04,,,percent of total billed charges,,,88.04,,,percent of total billed charges,,,88.04,,,percent of total billed charges,,,165.08,,,percent of total billed charges,,,220.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,220.11,,,percent of total billed charges,,,220.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,154.56,,,percent of total billed charges,,
FENTANYL 2MCG/BUP 0.125 250ML,2500032911,CDM,636,RC,999,EAPG,,,,,,outpatient,facility,250,UN,220.11,220.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TICAGRELOR 60 MG TAB,2500032912,CDM,637,RC,186077660,NDC,,,,,,inpatient,facility,60,UN,24.82,24.82,1.99,24.82,,,,,,,,,,,,,,24.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.34,,,percent of total billed charges,,,,,,,,,24.82,,,percent of total billed charges,,,13.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.82,,,percent of total billed charges,,,,,,,,,,,,,,,24.82,,,percent of total billed charges,,,12.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,24.82,,,percent of total billed charges,,,24.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.43,,,percent of total billed charges,,
TICAGRELOR 60 MG TAB,2500032912,CDM,637,RC,186077660,NDC,,,,,,outpatient,facility,60,UN,24.82,24.82,1.99,618.77,,14.49,,,percent of total billed charges,,,4.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,24.82,,,percent of total billed charges,,,21.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,21.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,21.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,24.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,9.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,22.34,,,percent of total billed charges,,,,,,,,,24.82,,,percent of total billed charges,,,16.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.06,,,percent of total billed charges,,,,,,,,,,,,,,,13.4,,,percent of total billed charges,,,13.4,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,24.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.94,,,percent of total billed charges,,,24.82,,,percent of total billed charges,,,24.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.86,,,percent of total billed charges,,,9.4,,,percent of total billed charges,,,12.85,,,percent of total billed charges,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,9.18,,,percent of total billed charges,,,9.18,,,percent of total billed charges,,,24.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.99,,,percent of total billed charges,,,24.82,,,percent of total billed charges,,,24.82,,,percent of total billed charges,,,,,,,,,,,,,,,24.82,,,percent of total billed charges,,,24.82,,,percent of total billed charges,,,,,,,,,24.82,,,fee schedule,,,23.09,,,percent of total billed charges,,,,,,,,,,,,,,,23.09,,,percent of total billed charges,,,23.09,,,percent of total billed charges,,,23.09,,,percent of total billed charges,,,18.62,,,percent of total billed charges,,,24.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,24.82,,,percent of total billed charges,,,24.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.43,,,percent of total billed charges,,
TICAGRELOR 60 MG TAB,2500032912,CDM,637,RC,186077660,NDC,999,EAPG,,,,outpatient,facility,60,UN,24.82,24.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 5  CRM 30 GM,2500032918,CDM,637,RC,3932802530,NDC,,,,,,inpatient,facility,30,UN,194.7,194.7,15.58,194.7,,,,,,,,,,,,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.23,,,percent of total billed charges,,,,,,,,,194.7,,,percent of total billed charges,,,107.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,194.7,,,percent of total billed charges,,,101.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.72,,,percent of total billed charges,,
LIDOCAINE 5  CRM 30 GM,2500032918,CDM,637,RC,3932802530,NDC,,,,,,outpatient,facility,30,UN,194.7,194.7,15.58,618.77,,113.7,,,percent of total billed charges,,,37.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,194.7,,,percent of total billed charges,,,171.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,171.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,171.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,71.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,175.23,,,percent of total billed charges,,,,,,,,,194.7,,,percent of total billed charges,,,131.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.53,,,percent of total billed charges,,,,,,,,,,,,,,,105.14,,,percent of total billed charges,,,105.14,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,101.52,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.97,,,percent of total billed charges,,,73.75,,,percent of total billed charges,,,100.84,,,percent of total billed charges,,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,72.04,,,percent of total billed charges,,,72.04,,,percent of total billed charges,,,194.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,194.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.58,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,194.7,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,,,,,,,194.7,,,fee schedule,,,181.11,,,percent of total billed charges,,,,,,,,,,,,,,,181.11,,,percent of total billed charges,,,181.11,,,percent of total billed charges,,,181.11,,,percent of total billed charges,,,146.02,,,percent of total billed charges,,,194.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,194.7,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,136.72,,,percent of total billed charges,,
LIDOCAINE 5  CRM 30 GM,2500032918,CDM,637,RC,3932802530,NDC,999,EAPG,,,,outpatient,facility,30,UN,194.7,194.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MENTHOL/METHYL SALIC CRM 57GM,2500032925,CDM,637,RC,7430008193,NDC,,,,,,inpatient,facility,57,UN,10.41,10.41,0.83,10.41,,,,,,,,,,,,,,10.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.37,,,percent of total billed charges,,,,,,,,,10.41,,,percent of total billed charges,,,5.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.41,,,percent of total billed charges,,,,,,,,,,,,,,,10.41,,,percent of total billed charges,,,5.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,10.41,,,percent of total billed charges,,,10.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.31,,,percent of total billed charges,,
MENTHOL/METHYL SALIC CRM 57GM,2500032925,CDM,637,RC,7430008193,NDC,,,,,,outpatient,facility,57,UN,10.41,10.41,0.83,618.77,,6.08,,,percent of total billed charges,,,2.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,10.41,,,percent of total billed charges,,,9.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,9.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,9.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,9.37,,,percent of total billed charges,,,,,,,,,10.41,,,percent of total billed charges,,,7.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.99,,,percent of total billed charges,,,,,,,,,,,,,,,5.62,,,percent of total billed charges,,,5.62,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,10.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.43,,,percent of total billed charges,,,10.41,,,percent of total billed charges,,,10.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.91,,,percent of total billed charges,,,3.94,,,percent of total billed charges,,,5.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3.85,,,percent of total billed charges,,,3.85,,,percent of total billed charges,,,10.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.83,,,percent of total billed charges,,,10.41,,,percent of total billed charges,,,10.41,,,percent of total billed charges,,,,,,,,,,,,,,,10.41,,,percent of total billed charges,,,10.41,,,percent of total billed charges,,,,,,,,,10.41,,,fee schedule,,,9.68,,,percent of total billed charges,,,,,,,,,,,,,,,9.68,,,percent of total billed charges,,,9.68,,,percent of total billed charges,,,9.68,,,percent of total billed charges,,,7.81,,,percent of total billed charges,,,10.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,10.41,,,percent of total billed charges,,,10.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.31,,,percent of total billed charges,,
MENTHOL/METHYL SALIC CRM 57GM,2500032925,CDM,637,RC,7430008193,NDC,999,EAPG,,,,outpatient,facility,57,UN,10.41,10.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SODIUM ZIRCONIUM CYCLO 10GM PK,2500032926,CDM,637,RC,310111039,NDC,,,,,,inpatient,facility,10,UN,90.26,90.26,7.22,90.26,,,,,,,,,,,,,,90.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.23,,,percent of total billed charges,,,,,,,,,90.26,,,percent of total billed charges,,,49.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.26,,,percent of total billed charges,,,,,,,,,,,,,,,90.26,,,percent of total billed charges,,,47.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,90.26,,,percent of total billed charges,,,90.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.38,,,percent of total billed charges,,
SODIUM ZIRCONIUM CYCLO 10GM PK,2500032926,CDM,637,RC,310111039,NDC,,,,,,outpatient,facility,10,UN,90.26,90.26,7.22,618.77,,52.71,,,percent of total billed charges,,,17.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,90.26,,,percent of total billed charges,,,79.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,79.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,79.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,90.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,33.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,81.23,,,percent of total billed charges,,,,,,,,,90.26,,,percent of total billed charges,,,61.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.32,,,percent of total billed charges,,,,,,,,,,,,,,,48.74,,,percent of total billed charges,,,48.74,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,90.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.06,,,percent of total billed charges,,,90.26,,,percent of total billed charges,,,90.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.6,,,percent of total billed charges,,,34.19,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,33.4,,,percent of total billed charges,,,33.4,,,percent of total billed charges,,,90.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,90.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.22,,,percent of total billed charges,,,90.26,,,percent of total billed charges,,,90.26,,,percent of total billed charges,,,,,,,,,,,,,,,90.26,,,percent of total billed charges,,,90.26,,,percent of total billed charges,,,,,,,,,90.26,,,fee schedule,,,83.96,,,percent of total billed charges,,,,,,,,,,,,,,,83.96,,,percent of total billed charges,,,83.96,,,percent of total billed charges,,,83.96,,,percent of total billed charges,,,67.7,,,percent of total billed charges,,,90.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,90.26,,,percent of total billed charges,,,90.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,63.38,,,percent of total billed charges,,
SODIUM ZIRCONIUM CYCLO 10GM PK,2500032926,CDM,637,RC,310111039,NDC,999,EAPG,,,,outpatient,facility,10,UN,90.26,90.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SODIUM ZIRCONIUM CYCLO 5GM PKT,2500032927,CDM,637,RC,310110539,NDC,,,,,,inpatient,facility,5,UN,90.25,90.25,7.22,90.25,,,,,,,,,,,,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.23,,,percent of total billed charges,,,,,,,,,90.25,,,percent of total billed charges,,,49.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,90.25,,,percent of total billed charges,,,47.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.37,,,percent of total billed charges,,
SODIUM ZIRCONIUM CYCLO 5GM PKT,2500032927,CDM,637,RC,310110539,NDC,,,,,,outpatient,facility,5,UN,90.25,90.25,7.22,618.77,,52.71,,,percent of total billed charges,,,17.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,90.25,,,percent of total billed charges,,,79.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,79.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,79.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,33.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,81.23,,,percent of total billed charges,,,,,,,,,90.25,,,percent of total billed charges,,,61.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.31,,,percent of total billed charges,,,,,,,,,,,,,,,48.74,,,percent of total billed charges,,,48.74,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.06,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.59,,,percent of total billed charges,,,34.19,,,percent of total billed charges,,,46.74,,,percent of total billed charges,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,33.39,,,percent of total billed charges,,,33.39,,,percent of total billed charges,,,90.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,90.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.22,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,90.25,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,,,,,,,90.25,,,fee schedule,,,83.95,,,percent of total billed charges,,,,,,,,,,,,,,,83.95,,,percent of total billed charges,,,83.95,,,percent of total billed charges,,,83.95,,,percent of total billed charges,,,67.69,,,percent of total billed charges,,,90.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,90.25,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,63.37,,,percent of total billed charges,,
SODIUM ZIRCONIUM CYCLO 5GM PKT,2500032927,CDM,637,RC,310110539,NDC,999,EAPG,,,,outpatient,facility,5,UN,90.25,90.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALOGLIPTIN 6.25 MG TAB,2500032931,CDM,637,RC,4580208765,NDC,,,,,,inpatient,facility,6.25,UN,21.45,21.45,1.72,21.45,,,,,,,,,,,,,,21.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.3,,,percent of total billed charges,,,,,,,,,21.45,,,percent of total billed charges,,,11.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.45,,,percent of total billed charges,,,,,,,,,,,,,,,21.45,,,percent of total billed charges,,,11.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,21.45,,,percent of total billed charges,,,21.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.06,,,percent of total billed charges,,
ALOGLIPTIN 6.25 MG TAB,2500032931,CDM,637,RC,4580208765,NDC,,,,,,outpatient,facility,6.25,UN,21.45,21.45,1.72,618.77,,12.53,,,percent of total billed charges,,,4.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,21.45,,,percent of total billed charges,,,18.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,18.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,18.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,21.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,19.3,,,percent of total billed charges,,,,,,,,,21.45,,,percent of total billed charges,,,14.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.47,,,percent of total billed charges,,,,,,,,,,,,,,,11.58,,,percent of total billed charges,,,11.58,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,21.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.18,,,percent of total billed charges,,,21.45,,,percent of total billed charges,,,21.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.3,,,percent of total billed charges,,,8.13,,,percent of total billed charges,,,11.11,,,percent of total billed charges,,,,,,,,,,,,,,,4.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,7.94,,,percent of total billed charges,,,7.94,,,percent of total billed charges,,,21.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.72,,,percent of total billed charges,,,21.45,,,percent of total billed charges,,,21.45,,,percent of total billed charges,,,,,,,,,,,,,,,21.45,,,percent of total billed charges,,,21.45,,,percent of total billed charges,,,,,,,,,21.45,,,fee schedule,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,19.95,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,16.09,,,percent of total billed charges,,,21.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,21.45,,,percent of total billed charges,,,21.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,15.06,,,percent of total billed charges,,
ALOGLIPTIN 6.25 MG TAB,2500032931,CDM,637,RC,4580208765,NDC,999,EAPG,,,,outpatient,facility,6.25,UN,21.45,21.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INTEGRA BMWD PER 1 SQ CM,2700000111,CDM,,,,,,,,,,inpatient,facility,1,UN,25097.18,25097.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INTEGRA BMWD PER 1 SQ CM,2700000111,CDM,,,,,,,,,,outpatient,facility,1,UN,25097.18,25097.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRIMATRIX PER 1 SQ CM,2700000133,CDM,,,,,,,,,,inpatient,facility,1,UN,19615.18,19615.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRIMATRIX PER 1 SQ CM,2700000133,CDM,,,,,,,,,,outpatient,facility,1,UN,19615.18,19615.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PURAPLY AM- SQCM,2700000165,CDM,,,,,,,,,,inpatient,facility,1,UN,20520,20520,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PURAPLY AM- SQCM,2700000165,CDM,,,,,,,,,,outpatient,facility,1,UN,20520,20520,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
"GRAFIX STRAVIX PRIME PL SQCM	",2700000215,CDM,,,,,,,,,,inpatient,facility,1,UN,6732,6732,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
"GRAFIX STRAVIX PRIME PL SQCM	",2700000215,CDM,,,,,,,,,,outpatient,facility,1,UN,6732,6732,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
"Theraskin Per Sq Centimeter	",2700000243,CDM,,,,,,,,,,inpatient,facility,1,UN,11380,11380,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
"Theraskin Per Sq Centimeter	",2700000243,CDM,,,,,,,,,,outpatient,facility,1,UN,11380,11380,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OASIS BURN MATRIX; PER 1 SQ,2700000319,CDM,,,,,,,,,,inpatient,facility,1,UN,3500,3500,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OASIS BURN MATRIX; PER 1 SQ,2700000319,CDM,,,,,,,,,,outpatient,facility,1,UN,3500,3500,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VISTASEAL FBRN SEALANT 10M,2700000335,CDM,,,,,,,,,,inpatient,facility,1,UN,1638.2,1638.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VISTASEAL FBRN SEALANT 10M,2700000335,CDM,,,,,,,,,,outpatient,facility,1,UN,1638.2,1638.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
I&D ABSC; SMPL OR SGL,2800000002,CDM,761,RC,10060,CPT,,,,,,inpatient,facility,,,529.02,529.02,42.32,529.02,,,,,,,,,,,,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.12,,,percent of total billed charges,,,,,,,,,529.02,,,percent of total billed charges,,,292.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,529.02,,,percent of total billed charges,,,275.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.32,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.48,,,percent of total billed charges,,
I&D ABSC; SMPL OR SGL,2800000002,CDM,761,RC,10060,CPT,,,,,,outpatient,facility,,,529.02,529.02,42.32,618.77,,308.95,,,percent of total billed charges,,,,,,,,,529.02,,,percent of total billed charges,,,287.94,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,476.12,,,percent of total billed charges,,,,,,,,,529.02,,,percent of total billed charges,,,358.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.29,,,percent of total billed charges,,,,,,,,,,,,,,,344.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",364.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,275.83,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.06,,,percent of total billed charges,,,200.39,,,percent of total billed charges,,,273.98,,,percent of total billed charges,,,,,,,,,,,,,,,105.8,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,497.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",221.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,42.32,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,529.02,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,,,,,,,235.97,,,fee schedule,,,568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,426.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",369.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",396.76,,,percent of total billed charges,,,529.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,529.02,,,percent of total billed charges,,,529.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,49.64,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
I&D ABSC; SMPL OR SGL,2800000002,CDM,761,RC,10060,CPT,5051,APC,,,,outpatient,facility,,,529.02,529.02,224.06,336.68,,,,,,,,239.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.51,,,fee schedule,,,,,,,,,232.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,243.76,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,,,,,,,336.68,,,fee schedule,,,,,,,,,,,,,,,239.13,,,fee schedule,,,,,,,,,,,,,,,224.06,,,fee schedule,,,248.44,,,fee schedule,,,247.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,245.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,239.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.78,,,fee schedule,,,232.19,,,fee schedule,,,246.59,,,fee schedule,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,235.97,,,fee schedule,,,,,,,,,235.97,,,fee schedule,,,,,,,,
I&D ABSC; SMPL OR SGL,2800000002,CDM,761,RC,10060,CPT,3,EAPG,,,,outpatient,facility,,,529.02,529.02,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
I&D ABSC; COMPL OR MULTI,2800000003,CDM,761,RC,10061,CPT,,,,,,inpatient,facility,,,549.59,549.59,43.97,549.59,,,,,,,,,,,,,,549.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,494.63,,,percent of total billed charges,,,,,,,,,549.59,,,percent of total billed charges,,,304.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,501.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,549.59,,,percent of total billed charges,,,,,,,,,,,,,,,549.59,,,percent of total billed charges,,,286.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.97,,,percent of total billed charges,,,549.59,,,percent of total billed charges,,,549.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,549.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.92,,,percent of total billed charges,,
I&D ABSC; COMPL OR MULTI,2800000003,CDM,761,RC,10061,CPT,,,,,,outpatient,facility,,,549.59,549.59,43.97,705.35,,320.96,,,percent of total billed charges,,,,,,,,,549.59,,,percent of total billed charges,,,512.54,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,549.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,494.63,,,percent of total billed charges,,,,,,,,,549.59,,,percent of total billed charges,,,372.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.09,,,percent of total billed charges,,,,,,,,,,,,,,,666.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",705.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,549.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,286.56,,,percent of total billed charges,,,549.59,,,percent of total billed charges,,,549.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,417.69,,,percent of total billed charges,,,208.18,,,percent of total billed charges,,,284.63,,,percent of total billed charges,,,,,,,,,,,,,,,109.92,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,497.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",221.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,43.97,,,percent of total billed charges,,,549.59,,,percent of total billed charges,,,549.59,,,percent of total billed charges,,,,,,,,,,,,,,,549.59,,,percent of total billed charges,,,549.59,,,percent of total billed charges,,,,,,,,,474.47,,,fee schedule,,,568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,426.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",369.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",412.19,,,percent of total billed charges,,,549.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,549.59,,,percent of total billed charges,,,549.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,62.85,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
I&D ABSC; COMPL OR MULTI,2800000003,CDM,761,RC,10061,CPT,5052,APC,,,,outpatient,facility,,,549.59,549.59,450.54,676.98,,,,,,,,480.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.55,,,fee schedule,,,,,,,,,466.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,490.12,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,,,,,,,676.98,,,fee schedule,,,,,,,,,,,,,,,480.82,,,fee schedule,,,,,,,,,,,,,,,450.54,,,fee schedule,,,499.56,,,fee schedule,,,498.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,493.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,480.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.39,,,fee schedule,,,466.88,,,fee schedule,,,495.82,,,fee schedule,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,474.47,,,fee schedule,,,,,,,,,474.47,,,fee schedule,,,,,,,,
I&D ABSC; COMPL OR MULTI,2800000003,CDM,761,RC,10061,CPT,3,EAPG,,,,outpatient,facility,,,549.59,549.59,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
I&D PILONID CYS; SMPL,2800000004,CDM,761,RC,10080,CPT,,,,,,inpatient,facility,,,1897.43,1897.43,151.79,1897.43,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1707.69,,,percent of total billed charges,,,,,,,,,1897.43,,,percent of total billed charges,,,1050.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1731.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,989.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,379.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.79,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1332.38,,,percent of total billed charges,,
I&D PILONID CYS; SMPL,2800000004,CDM,761,RC,10080,CPT,,,,,,outpatient,facility,,,1897.43,1897.43,62.85,1897.43,,1108.1,,,percent of total billed charges,,,,,,,,,1897.43,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1707.69,,,percent of total billed charges,,,,,,,,,1897.43,,,percent of total billed charges,,,1284.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1457.23,,,percent of total billed charges,,,,,,,,,,,,,,,666.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",705.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,989.32,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1442.05,,,percent of total billed charges,,,718.75,,,percent of total billed charges,,,982.68,,,percent of total billed charges,,,,,,,,,,,,,,,379.49,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,151.79,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1423.07,,,percent of total billed charges,,,1897.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1897.43,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,62.85,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
I&D PILONID CYS; SMPL,2800000004,CDM,761,RC,10080,CPT,5071,APC,,,,outpatient,facility,,,1897.43,1897.43,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
I&D PILONID CYS; SMPL,2800000004,CDM,761,RC,10080,CPT,3,EAPG,,,,outpatient,facility,,,1897.43,1897.43,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INC & REM FB SQ; SMPL,2800000005,CDM,761,RC,10120,CPT,,,,,,inpatient,facility,,,820.12,820.12,65.61,820.12,,,,,,,,,,,,,,820.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,738.11,,,percent of total billed charges,,,,,,,,,820.12,,,percent of total billed charges,,,454.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,748.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,820.12,,,percent of total billed charges,,,,,,,,,,,,,,,820.12,,,percent of total billed charges,,,427.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.61,,,percent of total billed charges,,,820.12,,,percent of total billed charges,,,820.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,820.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.89,,,percent of total billed charges,,
INC & REM FB SQ; SMPL,2800000005,CDM,761,RC,10120,CPT,,,,,,outpatient,facility,,,820.12,820.12,62.85,820.12,,478.95,,,percent of total billed charges,,,,,,,,,820.12,,,percent of total billed charges,,,512.54,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,820.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,738.11,,,percent of total billed charges,,,,,,,,,820.12,,,percent of total billed charges,,,555.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,629.85,,,percent of total billed charges,,,,,,,,,,,,,,,658.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",696.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,820.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,427.61,,,percent of total billed charges,,,820.12,,,percent of total billed charges,,,820.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,623.29,,,percent of total billed charges,,,310.66,,,percent of total billed charges,,,424.74,,,percent of total billed charges,,,,,,,,,,,,,,,164.02,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,497.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",221.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,65.61,,,percent of total billed charges,,,820.12,,,percent of total billed charges,,,820.12,,,percent of total billed charges,,,,,,,,,,,,,,,820.12,,,percent of total billed charges,,,820.12,,,percent of total billed charges,,,,,,,,,474.47,,,fee schedule,,,568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,426.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",369.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",615.09,,,percent of total billed charges,,,820.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,820.12,,,percent of total billed charges,,,820.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,62.85,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
INC & REM FB SQ; SMPL,2800000005,CDM,761,RC,10120,CPT,5052,APC,,,,outpatient,facility,,,820.12,820.12,450.54,676.98,,,,,,,,480.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.55,,,fee schedule,,,,,,,,,466.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,490.12,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,,,,,,,676.98,,,fee schedule,,,,,,,,,,,,,,,480.82,,,fee schedule,,,,,,,,,,,,,,,450.54,,,fee schedule,,,499.56,,,fee schedule,,,498.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,493.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,480.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.39,,,fee schedule,,,466.88,,,fee schedule,,,495.82,,,fee schedule,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,474.47,,,fee schedule,,,,,,,,,474.47,,,fee schedule,,,,,,,,
INC & REM FB SQ; SMPL,2800000005,CDM,761,RC,10120,CPT,3,EAPG,,,,outpatient,facility,,,820.12,820.12,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
I&D HEMATOMA/FLUID,2800000006,CDM,761,RC,10140,CPT,,,,,,inpatient,facility,,,2520.41,2520.41,201.63,2520.41,,,,,,,,,,,,,,2520.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2268.37,,,percent of total billed charges,,,,,,,,,2520.41,,,percent of total billed charges,,,1395.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2299.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2520.41,,,percent of total billed charges,,,,,,,,,,,,,,,2520.41,,,percent of total billed charges,,,1314.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,504.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.63,,,percent of total billed charges,,,2520.41,,,percent of total billed charges,,,2520.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2520.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1769.83,,,percent of total billed charges,,
I&D HEMATOMA/FLUID,2800000006,CDM,761,RC,10140,CPT,,,,,,outpatient,facility,,,2520.41,2520.41,73.92,2910.72,,1471.92,,,percent of total billed charges,,,,,,,,,2520.41,,,percent of total billed charges,,,2244.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,2520.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2268.37,,,percent of total billed charges,,,,,,,,,2520.41,,,percent of total billed charges,,,1706.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1935.67,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,2520.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.14,,,percent of total billed charges,,,2520.41,,,percent of total billed charges,,,2520.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1915.51,,,percent of total billed charges,,,954.73,,,percent of total billed charges,,,1305.32,,,percent of total billed charges,,,,,,,,,,,,,,,504.08,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,201.63,,,percent of total billed charges,,,2520.41,,,percent of total billed charges,,,2520.41,,,percent of total billed charges,,,,,,,,,,,,,,,2520.41,,,percent of total billed charges,,,2520.41,,,percent of total billed charges,,,,,,,,,1924.13,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1890.31,,,percent of total billed charges,,,2520.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2520.41,,,percent of total billed charges,,,2520.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1260.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,73.92,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
I&D HEMATOMA/FLUID,2800000006,CDM,761,RC,10140,CPT,5072,APC,,,,outpatient,facility,,,2520.41,2520.41,1827.07,2745.34,,,,,,,,1950.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1912.27,,,fee schedule,,,,,,,,,1893.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1987.63,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,,,,,,,2745.34,,,fee schedule,,,,,,,,,,,,,,,1949.91,,,fee schedule,,,,,,,,,,,,,,,1827.07,,,fee schedule,,,2025.87,,,fee schedule,,,2020.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1950.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.22,,,fee schedule,,,1893.34,,,fee schedule,,,2010.72,,,fee schedule,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1924.13,,,fee schedule,,,,,,,,,1924.13,,,fee schedule,,,,,,,,
I&D HEMATOMA/FLUID,2800000006,CDM,761,RC,10140,CPT,4,EAPG,,,,outpatient,facility,,,2520.41,2520.41,997.48,1462.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1462.31,,,fee schedule,,,997.48,,,fee schedule,,,1300.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.48,,,fee schedule,,,997.48,,,fee schedule,,,997.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,997.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REM SKIN TAGS; <=15 LESIONS,2800000010,CDM,761,RC,11200,CPT,,,,,,inpatient,facility,,,491.47,491.47,39.32,491.47,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.32,,,percent of total billed charges,,,,,,,,,491.47,,,percent of total billed charges,,,272.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,448.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,256.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.32,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.11,,,percent of total billed charges,,
REM SKIN TAGS; <=15 LESIONS,2800000010,CDM,761,RC,11200,CPT,,,,,,outpatient,facility,,,491.47,491.47,35.44,800,,287.02,,,percent of total billed charges,,,,,,,,,491.47,,,percent of total billed charges,,,287.94,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,442.32,,,percent of total billed charges,,,,,,,,,491.47,,,percent of total billed charges,,,332.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.45,,,percent of total billed charges,,,,,,,,,,,,,,,344.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",364.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,256.25,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,186.17,,,percent of total billed charges,,,254.53,,,percent of total billed charges,,,,,,,,,,,,,,,98.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,497.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",221.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,39.32,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,235.97,,,fee schedule,,,568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,426.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",369.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",368.6,,,percent of total billed charges,,,491.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.44,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
REM SKIN TAGS; <=15 LESIONS,2800000010,CDM,761,RC,11200,CPT,5051,APC,,,,outpatient,facility,,,491.47,491.47,224.06,336.68,,,,,,,,239.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.51,,,fee schedule,,,,,,,,,232.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,243.76,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,,,,,,,336.68,,,fee schedule,,,,,,,,,,,,,,,239.13,,,fee schedule,,,,,,,,,,,,,,,224.06,,,fee schedule,,,248.44,,,fee schedule,,,247.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,245.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,239.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.78,,,fee schedule,,,232.19,,,fee schedule,,,246.59,,,fee schedule,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,235.97,,,fee schedule,,,,,,,,,235.97,,,fee schedule,,,,,,,,
REM SKIN TAGS; <=15 LESIONS,2800000010,CDM,761,RC,11200,CPT,3,EAPG,,,,outpatient,facility,,,491.47,491.47,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHAVE LES T/A/L; 0.5CM/<,2800000011,CDM,761,RC,11300,CPT,,,,,,inpatient,facility,,,253.66,253.66,20.29,253.66,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,140.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,132.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.12,,,percent of total billed charges,,
SHAVE LES T/A/L; 0.5CM/<,2800000011,CDM,761,RC,11300,CPT,,,,,,outpatient,facility,,,253.66,253.66,20.29,618.77,,148.14,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,287.94,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,171.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.81,,,percent of total billed charges,,,,,,,,,,,,,,,344.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",364.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,132.26,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.78,,,percent of total billed charges,,,96.09,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,247.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",110.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,474.47,,,fee schedule,,,282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,212.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",183.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",190.25,,,percent of total billed charges,,,253.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.44,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
SHAVE LES T/A/L; 0.5CM/<,2800000011,CDM,761,RC,11300,CPT,5052,APC,,,,outpatient,facility,,,253.66,253.66,450.54,676.98,,,,,,,,480.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.55,,,fee schedule,,,,,,,,,466.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,490.12,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,,,,,,,676.98,,,fee schedule,,,,,,,,,,,,,,,480.82,,,fee schedule,,,,,,,,,,,,,,,450.54,,,fee schedule,,,499.56,,,fee schedule,,,498.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,493.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,480.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.39,,,fee schedule,,,466.88,,,fee schedule,,,495.82,,,fee schedule,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,474.47,,,fee schedule,,,,,,,,,474.47,,,fee schedule,,,,,,,,
SHAVE LES T/A/L; 0.5CM/<,2800000011,CDM,761,RC,11300,CPT,3,EAPG,,,,outpatient,facility,,,253.66,253.66,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHAVE LES T/A/L; 0.6-1.0CM,2800000012,CDM,761,RC,11301,CPT,,,,,,inpatient,facility,,,253.66,253.66,20.29,253.66,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,140.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,132.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.12,,,percent of total billed charges,,
SHAVE LES T/A/L; 0.6-1.0CM,2800000012,CDM,761,RC,11301,CPT,,,,,,outpatient,facility,,,253.66,253.66,20.29,618.77,,148.14,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,287.94,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,171.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.81,,,percent of total billed charges,,,,,,,,,,,,,,,344.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",364.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,132.26,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.78,,,percent of total billed charges,,,96.09,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,247.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",110.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,235.97,,,fee schedule,,,282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,212.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",183.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",190.25,,,percent of total billed charges,,,253.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.44,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
SHAVE LES T/A/L; 0.6-1.0CM,2800000012,CDM,761,RC,11301,CPT,5051,APC,,,,outpatient,facility,,,253.66,253.66,224.06,336.68,,,,,,,,239.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.51,,,fee schedule,,,,,,,,,232.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,243.76,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,,,,,,,336.68,,,fee schedule,,,,,,,,,,,,,,,239.13,,,fee schedule,,,,,,,,,,,,,,,224.06,,,fee schedule,,,248.44,,,fee schedule,,,247.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,245.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,239.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.78,,,fee schedule,,,232.19,,,fee schedule,,,246.59,,,fee schedule,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,235.97,,,fee schedule,,,,,,,,,235.97,,,fee schedule,,,,,,,,
SHAVE LES T/A/L; 0.6-1.0CM,2800000012,CDM,761,RC,11301,CPT,3,EAPG,,,,outpatient,facility,,,253.66,253.66,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHAVE LES T/A/L; 1.1-2.0CM,2800000013,CDM,761,RC,11302,CPT,,,,,,inpatient,facility,,,253.66,253.66,20.29,253.66,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,140.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,132.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.12,,,percent of total billed charges,,
SHAVE LES T/A/L; 1.1-2.0CM,2800000013,CDM,761,RC,11302,CPT,,,,,,outpatient,facility,,,253.66,253.66,20.29,618.77,,148.14,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,287.94,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,171.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.81,,,percent of total billed charges,,,,,,,,,,,,,,,344.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",364.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,132.26,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.78,,,percent of total billed charges,,,96.09,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,247.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",110.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,235.97,,,fee schedule,,,282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,212.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",183.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",190.25,,,percent of total billed charges,,,253.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.44,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
SHAVE LES T/A/L; 1.1-2.0CM,2800000013,CDM,761,RC,11302,CPT,5051,APC,,,,outpatient,facility,,,253.66,253.66,224.06,336.68,,,,,,,,239.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.51,,,fee schedule,,,,,,,,,232.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,243.76,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,,,,,,,336.68,,,fee schedule,,,,,,,,,,,,,,,239.13,,,fee schedule,,,,,,,,,,,,,,,224.06,,,fee schedule,,,248.44,,,fee schedule,,,247.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,245.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,239.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.78,,,fee schedule,,,232.19,,,fee schedule,,,246.59,,,fee schedule,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,235.97,,,fee schedule,,,,,,,,,235.97,,,fee schedule,,,,,,,,
SHAVE LES T/A/L; 1.1-2.0CM,2800000013,CDM,761,RC,11302,CPT,3,EAPG,,,,outpatient,facility,,,253.66,253.66,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHAVE LES S/N/H/F/G; 0.5CM/<,2800000014,CDM,761,RC,11305,CPT,,,,,,inpatient,facility,,,253.66,253.66,20.29,253.66,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,140.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,132.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.12,,,percent of total billed charges,,
SHAVE LES S/N/H/F/G; 0.5CM/<,2800000014,CDM,761,RC,11305,CPT,,,,,,outpatient,facility,,,253.66,253.66,20.29,618.77,,148.14,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,287.94,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,171.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.81,,,percent of total billed charges,,,,,,,,,,,,,,,344.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",364.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,132.26,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.78,,,percent of total billed charges,,,96.09,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,247.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",110.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,235.97,,,fee schedule,,,282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,212.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",183.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",190.25,,,percent of total billed charges,,,253.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.31,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
SHAVE LES S/N/H/F/G; 0.5CM/<,2800000014,CDM,761,RC,11305,CPT,5051,APC,,,,outpatient,facility,,,253.66,253.66,224.06,336.68,,,,,,,,239.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.51,,,fee schedule,,,,,,,,,232.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,243.76,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,,,,,,,336.68,,,fee schedule,,,,,,,,,,,,,,,239.13,,,fee schedule,,,,,,,,,,,,,,,224.06,,,fee schedule,,,248.44,,,fee schedule,,,247.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,245.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,239.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.78,,,fee schedule,,,232.19,,,fee schedule,,,246.59,,,fee schedule,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,235.97,,,fee schedule,,,,,,,,,235.97,,,fee schedule,,,,,,,,
SHAVE LES S/N/H/F/G; 0.5CM/<,2800000014,CDM,761,RC,11305,CPT,3,EAPG,,,,outpatient,facility,,,253.66,253.66,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHAVE LES S/N/H/F/G; 0.6-1.0CM,2800000015,CDM,761,RC,11306,CPT,,,,,,inpatient,facility,,,253.66,253.66,20.29,253.66,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,140.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,132.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.12,,,percent of total billed charges,,
SHAVE LES S/N/H/F/G; 0.6-1.0CM,2800000015,CDM,761,RC,11306,CPT,,,,,,outpatient,facility,,,253.66,253.66,20.29,618.77,,148.14,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,287.94,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,171.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.81,,,percent of total billed charges,,,,,,,,,,,,,,,344.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",364.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,132.26,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.78,,,percent of total billed charges,,,96.09,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,247.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",110.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,235.97,,,fee schedule,,,282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,212.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",183.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",190.25,,,percent of total billed charges,,,253.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.44,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
SHAVE LES S/N/H/F/G; 0.6-1.0CM,2800000015,CDM,761,RC,11306,CPT,5051,APC,,,,outpatient,facility,,,253.66,253.66,224.06,336.68,,,,,,,,239.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.51,,,fee schedule,,,,,,,,,232.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,243.76,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,,,,,,,336.68,,,fee schedule,,,,,,,,,,,,,,,239.13,,,fee schedule,,,,,,,,,,,,,,,224.06,,,fee schedule,,,248.44,,,fee schedule,,,247.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,245.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,239.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.78,,,fee schedule,,,232.19,,,fee schedule,,,246.59,,,fee schedule,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,235.97,,,fee schedule,,,,,,,,,235.97,,,fee schedule,,,,,,,,
SHAVE LES S/N/H/F/G; 0.6-1.0CM,2800000015,CDM,761,RC,11306,CPT,3,EAPG,,,,outpatient,facility,,,253.66,253.66,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHAVE LES S/N/H/F/G; 1.1-2.0CM,2800000016,CDM,761,RC,11307,CPT,,,,,,inpatient,facility,,,253.66,253.66,20.29,253.66,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,140.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,132.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.12,,,percent of total billed charges,,
SHAVE LES S/N/H/F/G; 1.1-2.0CM,2800000016,CDM,761,RC,11307,CPT,,,,,,outpatient,facility,,,253.66,253.66,20.29,696.95,,148.14,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,287.94,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,171.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.81,,,percent of total billed charges,,,,,,,,,,,,,,,658.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",696.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,132.26,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.78,,,percent of total billed charges,,,96.09,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,247.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",110.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,235.97,,,fee schedule,,,282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,212.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",183.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",190.25,,,percent of total billed charges,,,253.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.44,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
SHAVE LES S/N/H/F/G; 1.1-2.0CM,2800000016,CDM,761,RC,11307,CPT,5051,APC,,,,outpatient,facility,,,253.66,253.66,224.06,336.68,,,,,,,,239.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.51,,,fee schedule,,,,,,,,,232.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,243.76,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,,,,,,,336.68,,,fee schedule,,,,,,,,,,,,,,,239.13,,,fee schedule,,,,,,,,,,,,,,,224.06,,,fee schedule,,,248.44,,,fee schedule,,,247.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,245.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,239.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.78,,,fee schedule,,,232.19,,,fee schedule,,,246.59,,,fee schedule,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,235.97,,,fee schedule,,,,,,,,,235.97,,,fee schedule,,,,,,,,
SHAVE LES S/N/H/F/G; 1.1-2.0CM,2800000016,CDM,761,RC,11307,CPT,3,EAPG,,,,outpatient,facility,,,253.66,253.66,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHAVE LES S/N/H/F/G; > 2.0CM,2800000017,CDM,761,RC,11308,CPT,,,,,,inpatient,facility,,,491.47,491.47,39.32,491.47,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.32,,,percent of total billed charges,,,,,,,,,491.47,,,percent of total billed charges,,,272.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,448.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,256.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.32,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.11,,,percent of total billed charges,,
SHAVE LES S/N/H/F/G; > 2.0CM,2800000017,CDM,761,RC,11308,CPT,,,,,,outpatient,facility,,,491.47,491.47,35.44,618.77,,287.02,,,percent of total billed charges,,,,,,,,,491.47,,,percent of total billed charges,,,512.54,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,442.32,,,percent of total billed charges,,,,,,,,,491.47,,,percent of total billed charges,,,332.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.45,,,percent of total billed charges,,,,,,,,,,,,,,,344.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",364.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,256.25,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.52,,,percent of total billed charges,,,186.17,,,percent of total billed charges,,,254.53,,,percent of total billed charges,,,,,,,,,,,,,,,98.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,497.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",221.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,39.32,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,474.47,,,fee schedule,,,568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,426.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",369.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",368.6,,,percent of total billed charges,,,491.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.44,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
SHAVE LES S/N/H/F/G; > 2.0CM,2800000017,CDM,761,RC,11308,CPT,5052,APC,,,,outpatient,facility,,,491.47,491.47,450.54,676.98,,,,,,,,480.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.55,,,fee schedule,,,,,,,,,466.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,490.12,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,,,,,,,676.98,,,fee schedule,,,,,,,,,,,,,,,480.82,,,fee schedule,,,,,,,,,,,,,,,450.54,,,fee schedule,,,499.56,,,fee schedule,,,498.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,493.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,480.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.39,,,fee schedule,,,466.88,,,fee schedule,,,495.82,,,fee schedule,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,474.47,,,fee schedule,,,,,,,,,474.47,,,fee schedule,,,,,,,,
SHAVE LES S/N/H/F/G; > 2.0CM,2800000017,CDM,761,RC,11308,CPT,3,EAPG,,,,outpatient,facility,,,491.47,491.47,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHAVE LES F/E/N/L; 0.5CM/<,2800000018,CDM,761,RC,11310,CPT,,,,,,inpatient,facility,,,253.66,253.66,20.29,253.66,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,140.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,132.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.12,,,percent of total billed charges,,
SHAVE LES F/E/N/L; 0.5CM/<,2800000018,CDM,761,RC,11310,CPT,,,,,,outpatient,facility,,,253.66,253.66,20.29,696.95,,148.14,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,287.94,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,171.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.81,,,percent of total billed charges,,,,,,,,,,,,,,,658.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",696.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,132.26,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.78,,,percent of total billed charges,,,96.09,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,247.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",110.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,235.97,,,fee schedule,,,282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,212.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",183.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",190.25,,,percent of total billed charges,,,253.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.44,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
SHAVE LES F/E/N/L; 0.5CM/<,2800000018,CDM,761,RC,11310,CPT,5051,APC,,,,outpatient,facility,,,253.66,253.66,224.06,336.68,,,,,,,,239.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.51,,,fee schedule,,,,,,,,,232.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,243.76,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,,,,,,,336.68,,,fee schedule,,,,,,,,,,,,,,,239.13,,,fee schedule,,,,,,,,,,,,,,,224.06,,,fee schedule,,,248.44,,,fee schedule,,,247.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,245.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,239.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.78,,,fee schedule,,,232.19,,,fee schedule,,,246.59,,,fee schedule,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,235.97,,,fee schedule,,,,,,,,,235.97,,,fee schedule,,,,,,,,
SHAVE LES F/E/N/L; 0.5CM/<,2800000018,CDM,761,RC,11310,CPT,3,EAPG,,,,outpatient,facility,,,253.66,253.66,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHAVE LES F/E/N/L; 0.6-1.0CM,2800000019,CDM,761,RC,11311,CPT,,,,,,inpatient,facility,,,253.66,253.66,20.29,253.66,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,140.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,132.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.12,,,percent of total billed charges,,
SHAVE LES F/E/N/L; 0.6-1.0CM,2800000019,CDM,761,RC,11311,CPT,,,,,,outpatient,facility,,,253.66,253.66,20.29,696.95,,148.14,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,287.94,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,171.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.81,,,percent of total billed charges,,,,,,,,,,,,,,,658.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",696.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,132.26,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.78,,,percent of total billed charges,,,96.09,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,247.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",110.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,235.97,,,fee schedule,,,282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,212.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",183.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",190.25,,,percent of total billed charges,,,253.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.44,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
SHAVE LES F/E/N/L; 0.6-1.0CM,2800000019,CDM,761,RC,11311,CPT,5051,APC,,,,outpatient,facility,,,253.66,253.66,224.06,336.68,,,,,,,,239.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.51,,,fee schedule,,,,,,,,,232.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,243.76,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,,,,,,,336.68,,,fee schedule,,,,,,,,,,,,,,,239.13,,,fee schedule,,,,,,,,,,,,,,,224.06,,,fee schedule,,,248.44,,,fee schedule,,,247.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,245.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,239.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.78,,,fee schedule,,,232.19,,,fee schedule,,,246.59,,,fee schedule,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,235.97,,,fee schedule,,,,,,,,,235.97,,,fee schedule,,,,,,,,
SHAVE LES F/E/N/L; 0.6-1.0CM,2800000019,CDM,761,RC,11311,CPT,3,EAPG,,,,outpatient,facility,,,253.66,253.66,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHAVE LES F/E/N/L; 1.1-2.0CM,2800000020,CDM,761,RC,11312,CPT,,,,,,inpatient,facility,,,491.47,491.47,39.32,491.47,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.32,,,percent of total billed charges,,,,,,,,,491.47,,,percent of total billed charges,,,272.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,448.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,256.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.32,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.11,,,percent of total billed charges,,
SHAVE LES F/E/N/L; 1.1-2.0CM,2800000020,CDM,761,RC,11312,CPT,,,,,,outpatient,facility,,,491.47,491.47,35.44,696.95,,287.02,,,percent of total billed charges,,,,,,,,,491.47,,,percent of total billed charges,,,512.54,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,442.32,,,percent of total billed charges,,,,,,,,,491.47,,,percent of total billed charges,,,332.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.45,,,percent of total billed charges,,,,,,,,,,,,,,,658.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",696.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,256.25,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.52,,,percent of total billed charges,,,186.17,,,percent of total billed charges,,,254.53,,,percent of total billed charges,,,,,,,,,,,,,,,98.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,497.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",221.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,39.32,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,474.47,,,fee schedule,,,568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,426.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",369.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",368.6,,,percent of total billed charges,,,491.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.44,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
SHAVE LES F/E/N/L; 1.1-2.0CM,2800000020,CDM,761,RC,11312,CPT,5052,APC,,,,outpatient,facility,,,491.47,491.47,450.54,676.98,,,,,,,,480.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.55,,,fee schedule,,,,,,,,,466.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,490.12,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,,,,,,,676.98,,,fee schedule,,,,,,,,,,,,,,,480.82,,,fee schedule,,,,,,,,,,,,,,,450.54,,,fee schedule,,,499.56,,,fee schedule,,,498.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,493.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,480.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.39,,,fee schedule,,,466.88,,,fee schedule,,,495.82,,,fee schedule,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,474.47,,,fee schedule,,,,,,,,,474.47,,,fee schedule,,,,,,,,
SHAVE LES F/E/N/L; 1.1-2.0CM,2800000020,CDM,761,RC,11312,CPT,3,EAPG,,,,outpatient,facility,,,491.47,491.47,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC TR-EXT B9+MARG 0.5CM/<,2800000021,CDM,761,RC,11400,CPT,,,,,,inpatient,facility,,,1108.7,1108.7,88.7,1108.7,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,613.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1011.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,578.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,778.53,,,percent of total billed charges,,
EXC TR-EXT B9+MARG 0.5CM/<,2800000021,CDM,761,RC,11400,CPT,,,,,,outpatient,facility,,,1108.7,1108.7,71.34,1485.18,,647.48,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,750.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,851.48,,,percent of total billed charges,,,,,,,,,,,,,,,1403.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",1485.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,578.08,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,419.98,,,percent of total billed charges,,,574.2,,,percent of total billed charges,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",831.53,,,percent of total billed charges,,,1108.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,554.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,71.34,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC TR-EXT B9+MARG 0.5CM/<,2800000021,CDM,761,RC,11400,CPT,5071,APC,,,,outpatient,facility,,,1108.7,1108.7,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC TR-EXT B9+MARG 0.5CM/<,2800000021,CDM,761,RC,11400,CPT,9,EAPG,,,,outpatient,facility,,,1108.7,1108.7,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC BEN LES T/A/L; 0.6-1.0CM,2800000022,CDM,761,RC,11401,CPT,,,,,,inpatient,facility,,,1108.7,1108.7,88.7,1108.7,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,613.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1011.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,578.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,778.53,,,percent of total billed charges,,
EXC BEN LES T/A/L; 0.6-1.0CM,2800000022,CDM,761,RC,11401,CPT,,,,,,outpatient,facility,,,1108.7,1108.7,77.95,1485.18,,647.48,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,512.54,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,750.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,851.48,,,percent of total billed charges,,,,,,,,,,,,,,,1403.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",1485.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,578.08,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,419.98,,,percent of total billed charges,,,574.2,,,percent of total billed charges,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,474.47,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",831.53,,,percent of total billed charges,,,1108.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,554.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,77.95,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC BEN LES T/A/L; 0.6-1.0CM,2800000022,CDM,761,RC,11401,CPT,5052,APC,,,,outpatient,facility,,,1108.7,1108.7,450.54,676.98,,,,,,,,480.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.55,,,fee schedule,,,,,,,,,466.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,490.12,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,,,,,,,676.98,,,fee schedule,,,,,,,,,,,,,,,480.82,,,fee schedule,,,,,,,,,,,,,,,450.54,,,fee schedule,,,499.56,,,fee schedule,,,498.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,493.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,480.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.39,,,fee schedule,,,466.88,,,fee schedule,,,495.82,,,fee schedule,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,474.47,,,fee schedule,,,,,,,,,474.47,,,fee schedule,,,,,,,,
EXC BEN LES T/A/L; 0.6-1.0CM,2800000022,CDM,761,RC,11401,CPT,9,EAPG,,,,outpatient,facility,,,1108.7,1108.7,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC BEN LES T/A/L; 1.1-2.0CM,2800000023,CDM,761,RC,11402,CPT,,,,,,inpatient,facility,,,1108.7,1108.7,88.7,1108.7,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,613.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1011.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,578.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,778.53,,,percent of total billed charges,,
EXC BEN LES T/A/L; 1.1-2.0CM,2800000023,CDM,761,RC,11402,CPT,,,,,,outpatient,facility,,,1108.7,1108.7,84.95,1485.18,,647.48,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,750.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,851.48,,,percent of total billed charges,,,,,,,,,,,,,,,1403.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",1485.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,578.08,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,419.98,,,percent of total billed charges,,,574.2,,,percent of total billed charges,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",831.53,,,percent of total billed charges,,,1108.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,554.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,84.95,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC BEN LES T/A/L; 1.1-2.0CM,2800000023,CDM,761,RC,11402,CPT,5071,APC,,,,outpatient,facility,,,1108.7,1108.7,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC BEN LES T/A/L; 1.1-2.0CM,2800000023,CDM,761,RC,11402,CPT,9,EAPG,,,,outpatient,facility,,,1108.7,1108.7,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC BEN LES T/A/L; 2.1-3.0CM,2800000024,CDM,761,RC,11403,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC BEN LES T/A/L; 2.1-3.0CM,2800000024,CDM,761,RC,11403,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,90.83,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,90.83,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC BEN LES T/A/L; 2.1-3.0CM,2800000024,CDM,761,RC,11403,CPT,5071,APC,,,,outpatient,facility,,,1821.6,1821.6,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC BEN LES T/A/L; 2.1-3.0CM,2800000024,CDM,761,RC,11403,CPT,9,EAPG,,,,outpatient,facility,,,1821.6,1821.6,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC BEN LES T/A/L; 3.1-4.0CM,2800000025,CDM,761,RC,11404,CPT,,,,,,inpatient,facility,,,3258.12,3258.12,260.65,3258.12,,,,,,,,,,,,,,3258.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2932.31,,,percent of total billed charges,,,,,,,,,3258.12,,,percent of total billed charges,,,1803.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3258.12,,,percent of total billed charges,,,,,,,,,,,,,,,3258.12,,,percent of total billed charges,,,1698.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,260.65,,,percent of total billed charges,,,3258.12,,,percent of total billed charges,,,3258.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3258.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2287.85,,,percent of total billed charges,,
EXC BEN LES T/A/L; 3.1-4.0CM,2800000025,CDM,761,RC,11404,CPT,,,,,,outpatient,facility,,,3258.12,3258.12,260.65,3258.12,,1902.74,,,percent of total billed charges,,,,,,,,,3258.12,,,percent of total billed charges,,,2244.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,3258.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2932.31,,,percent of total billed charges,,,,,,,,,3258.12,,,percent of total billed charges,,,2206.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2502.24,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,3258.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1698.78,,,percent of total billed charges,,,3258.12,,,percent of total billed charges,,,3258.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,1234.18,,,percent of total billed charges,,,1687.38,,,percent of total billed charges,,,,,,,,,,,,,,,651.62,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,260.65,,,percent of total billed charges,,,3258.12,,,percent of total billed charges,,,3258.12,,,percent of total billed charges,,,,,,,,,,,,,,,3258.12,,,percent of total billed charges,,,3258.12,,,percent of total billed charges,,,,,,,,,1924.13,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",2443.59,,,percent of total billed charges,,,3258.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,3258.12,,,percent of total billed charges,,,3258.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1629.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,719.48,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC BEN LES T/A/L; 3.1-4.0CM,2800000025,CDM,761,RC,11404,CPT,5072,APC,,,,outpatient,facility,,,3258.12,3258.12,1827.07,2745.34,,,,,,,,1950.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1912.27,,,fee schedule,,,,,,,,,1893.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1987.63,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,,,,,,,2745.34,,,fee schedule,,,,,,,,,,,,,,,1949.91,,,fee schedule,,,,,,,,,,,,,,,1827.07,,,fee schedule,,,2025.87,,,fee schedule,,,2020.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1950.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.22,,,fee schedule,,,1893.34,,,fee schedule,,,2010.72,,,fee schedule,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1924.13,,,fee schedule,,,,,,,,,1924.13,,,fee schedule,,,,,,,,
EXC BEN LES T/A/L; 3.1-4.0CM,2800000025,CDM,761,RC,11404,CPT,10,EAPG,,,,outpatient,facility,,,3258.12,3258.12,1234.87,1810.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1810.32,,,fee schedule,,,1234.87,,,fee schedule,,,1609.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC BEN LES T/A/L; > 4.0CM,2800000026,CDM,761,RC,11406,CPT,,,,,,inpatient,facility,,,4367.96,4367.96,349.44,4367.96,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3931.16,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2418.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3985.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,2277.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.44,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3067.18,,,percent of total billed charges,,
EXC BEN LES T/A/L; > 4.0CM,2800000026,CDM,761,RC,11406,CPT,,,,,,outpatient,facility,,,4367.96,4367.96,319.69,4428.39,,2550.89,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2244.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3931.16,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2957.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3354.59,,,percent of total billed charges,,,,,,,,,,,,,,,4129.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",4370.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2277.45,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1250,,,case rate,,,1654.58,,,percent of total billed charges,,,2262.17,,,percent of total billed charges,,,,,,,,,,,,,,,873.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3873.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",1726.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,349.44,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,1924.13,,,fee schedule,,,4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,3321.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",2878.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",3275.97,,,percent of total billed charges,,,4367.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2183.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,719.48,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC BEN LES T/A/L; > 4.0CM,2800000026,CDM,761,RC,11406,CPT,5072,APC,,,,outpatient,facility,,,4367.96,4367.96,1827.07,2745.34,,,,,,,,1950.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1912.27,,,fee schedule,,,,,,,,,1893.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1987.63,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,,,,,,,2745.34,,,fee schedule,,,,,,,,,,,,,,,1949.91,,,fee schedule,,,,,,,,,,,,,,,1827.07,,,fee schedule,,,2025.87,,,fee schedule,,,2020.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1950.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.22,,,fee schedule,,,1893.34,,,fee schedule,,,2010.72,,,fee schedule,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1924.13,,,fee schedule,,,,,,,,,1924.13,,,fee schedule,,,,,,,,
EXC BEN LES T/A/L; > 4.0CM,2800000026,CDM,761,RC,11406,CPT,11,EAPG,,,,outpatient,facility,,,4367.96,4367.96,2052.64,3009.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3009.17,,,fee schedule,,,2052.64,,,fee schedule,,,2675.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,2052.64,,,fee schedule,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC BLES S/N/EX G; 0.5CM/<,2800000027,CDM,761,RC,11420,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC BLES S/N/EX G; 0.5CM/<,2800000027,CDM,761,RC,11420,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,65.82,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,2244.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,1924.13,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,65.82,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC BLES S/N/EX G; 0.5CM/<,2800000027,CDM,761,RC,11420,CPT,5072,APC,,,,outpatient,facility,,,1821.6,1821.6,1827.07,2745.34,,,,,,,,1950.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1912.27,,,fee schedule,,,,,,,,,1893.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1987.63,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,,,,,,,2745.34,,,fee schedule,,,,,,,,,,,,,,,1949.91,,,fee schedule,,,,,,,,,,,,,,,1827.07,,,fee schedule,,,2025.87,,,fee schedule,,,2020.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1950.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.22,,,fee schedule,,,1893.34,,,fee schedule,,,2010.72,,,fee schedule,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1924.13,,,fee schedule,,,,,,,,,1924.13,,,fee schedule,,,,,,,,
EXC BLES S/N/EX G; 0.5CM/<,2800000027,CDM,761,RC,11420,CPT,10,EAPG,,,,outpatient,facility,,,1821.6,1821.6,1234.87,1810.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1810.32,,,fee schedule,,,1234.87,,,fee schedule,,,1609.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC BLES S/N/EX G; 0.6-1.0CM,2800000028,CDM,761,RC,11421,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC BLES S/N/EX G; 0.6-1.0CM,2800000028,CDM,761,RC,11421,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,78.7,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,78.7,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC BLES S/N/EX G; 0.6-1.0CM,2800000028,CDM,761,RC,11421,CPT,5071,APC,,,,outpatient,facility,,,1821.6,1821.6,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC BLES S/N/EX G; 0.6-1.0CM,2800000028,CDM,761,RC,11421,CPT,9,EAPG,,,,outpatient,facility,,,1821.6,1821.6,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC BLES S/N/EX G; 1.1-2.0CM,2800000029,CDM,761,RC,11422,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC BLES S/N/EX G; 1.1-2.0CM,2800000029,CDM,761,RC,11422,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,86.05,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,2244.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,1924.13,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,86.05,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC BLES S/N/EX G; 1.1-2.0CM,2800000029,CDM,761,RC,11422,CPT,5072,APC,,,,outpatient,facility,,,1821.6,1821.6,1827.07,2745.34,,,,,,,,1950.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1912.27,,,fee schedule,,,,,,,,,1893.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1987.63,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,,,,,,,2745.34,,,fee schedule,,,,,,,,,,,,,,,1949.91,,,fee schedule,,,,,,,,,,,,,,,1827.07,,,fee schedule,,,2025.87,,,fee schedule,,,2020.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1950.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.22,,,fee schedule,,,1893.34,,,fee schedule,,,2010.72,,,fee schedule,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1924.13,,,fee schedule,,,,,,,,,1924.13,,,fee schedule,,,,,,,,
EXC BLES S/N/EX G; 1.1-2.0CM,2800000029,CDM,761,RC,11422,CPT,10,EAPG,,,,outpatient,facility,,,1821.6,1821.6,1234.87,1810.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1810.32,,,fee schedule,,,1234.87,,,fee schedule,,,1609.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC BLES S/N/EX G; 2.1-3.0CM,2800000030,CDM,761,RC,11423,CPT,,,,,,inpatient,facility,,,4367.96,4367.96,349.44,4367.96,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3931.16,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2418.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3985.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,2277.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.44,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3067.18,,,percent of total billed charges,,
EXC BLES S/N/EX G; 2.1-3.0CM,2800000030,CDM,761,RC,11423,CPT,,,,,,outpatient,facility,,,4367.96,4367.96,96.35,4428.39,,2550.89,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2244.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3931.16,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2957.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3354.59,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2277.45,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,1654.58,,,percent of total billed charges,,,2262.17,,,percent of total billed charges,,,,,,,,,,,,,,,873.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3873.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",1726.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,349.44,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,1924.13,,,fee schedule,,,4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,3321.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",2878.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",3275.97,,,percent of total billed charges,,,4367.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2183.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,96.35,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC BLES S/N/EX G; 2.1-3.0CM,2800000030,CDM,761,RC,11423,CPT,5072,APC,,,,outpatient,facility,,,4367.96,4367.96,1827.07,2745.34,,,,,,,,1950.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1912.27,,,fee schedule,,,,,,,,,1893.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1987.63,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,,,,,,,2745.34,,,fee schedule,,,,,,,,,,,,,,,1949.91,,,fee schedule,,,,,,,,,,,,,,,1827.07,,,fee schedule,,,2025.87,,,fee schedule,,,2020.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1950.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.22,,,fee schedule,,,1893.34,,,fee schedule,,,2010.72,,,fee schedule,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1924.13,,,fee schedule,,,,,,,,,1924.13,,,fee schedule,,,,,,,,
EXC BLES S/N/EX G; 2.1-3.0CM,2800000030,CDM,761,RC,11423,CPT,10,EAPG,,,,outpatient,facility,,,4367.96,4367.96,1234.87,1810.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1810.32,,,fee schedule,,,1234.87,,,fee schedule,,,1609.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC BLES S/N/EX G; 3.1-4.0CM,2800000031,CDM,761,RC,11424,CPT,,,,,,inpatient,facility,,,4367.96,4367.96,349.44,4367.96,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3931.16,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2418.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3985.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,2277.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.44,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3067.18,,,percent of total billed charges,,
EXC BLES S/N/EX G; 3.1-4.0CM,2800000031,CDM,761,RC,11424,CPT,,,,,,outpatient,facility,,,4367.96,4367.96,319.69,4428.39,,2550.89,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2244.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3931.16,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2957.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3354.59,,,percent of total billed charges,,,,,,,,,,,,,,,4129.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",4370.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2277.45,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1250,,,case rate,,,1654.58,,,percent of total billed charges,,,2262.17,,,percent of total billed charges,,,,,,,,,,,,,,,873.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3873.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",1726.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,349.44,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,1924.13,,,fee schedule,,,4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,3321.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",2878.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",3275.97,,,percent of total billed charges,,,4367.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2183.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,719.48,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC BLES S/N/EX G; 3.1-4.0CM,2800000031,CDM,761,RC,11424,CPT,5072,APC,,,,outpatient,facility,,,4367.96,4367.96,1827.07,2745.34,,,,,,,,1950.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1912.27,,,fee schedule,,,,,,,,,1893.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1987.63,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,,,,,,,2745.34,,,fee schedule,,,,,,,,,,,,,,,1949.91,,,fee schedule,,,,,,,,,,,,,,,1827.07,,,fee schedule,,,2025.87,,,fee schedule,,,2020.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1950.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.22,,,fee schedule,,,1893.34,,,fee schedule,,,2010.72,,,fee schedule,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1924.13,,,fee schedule,,,,,,,,,1924.13,,,fee schedule,,,,,,,,
EXC BLES S/N/EX G; 3.1-4.0CM,2800000031,CDM,761,RC,11424,CPT,10,EAPG,,,,outpatient,facility,,,4367.96,4367.96,1234.87,1810.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1810.32,,,fee schedule,,,1234.87,,,fee schedule,,,1609.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC BLES S/N/EX G; > 4.0CM,2800000032,CDM,761,RC,11426,CPT,,,,,,inpatient,facility,,,4935.57,4935.57,394.85,4935.57,,,,,,,,,,,,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4442.01,,,percent of total billed charges,,,,,,,,,4935.57,,,percent of total billed charges,,,2732.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4503.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,4935.57,,,percent of total billed charges,,,2573.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,987.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,394.85,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3465.76,,,percent of total billed charges,,
EXC BLES S/N/EX G; > 4.0CM,2800000032,CDM,761,RC,11426,CPT,,,,,,outpatient,facility,,,4935.57,4935.57,319.69,4935.57,,2882.37,,,percent of total billed charges,,,,,,,,,4935.57,,,percent of total billed charges,,,3881.03,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,4318.9,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,4318.9,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4442.01,,,percent of total billed charges,,,,,,,,,4935.57,,,percent of total billed charges,,,3342.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3790.52,,,percent of total billed charges,,,,,,,,,,,,,,,4129.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",4370.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2573.41,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1250,,,case rate,,,1869.59,,,percent of total billed charges,,,2556.13,,,percent of total billed charges,,,,,,,,,,,,,,,987.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3873.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",1726.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,394.85,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,4935.57,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,,,,,,,3398.86,,,fee schedule,,,4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,3321.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",2878.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",3701.68,,,percent of total billed charges,,,4935.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4935.57,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2467.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,943.36,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC BLES S/N/EX G; > 4.0CM,2800000032,CDM,761,RC,11426,CPT,5073,APC,,,,outpatient,facility,,,4935.57,4935.57,3227.42,4849.5,,,,,,,,3444.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3377.92,,,fee schedule,,,,,,,,,3344.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,3511.02,,,fee schedule,,,3511.7,,,fee schedule,,,,,,,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,3511.7,,,fee schedule,,,,,,,,,,,,,,,4849.5,,,fee schedule,,,,,,,,,,,,,,,3444.41,,,fee schedule,,,,,,,,,,,,,,,3227.42,,,fee schedule,,,3578.59,,,fee schedule,,,3568.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3534.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4180.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,3444.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3743.97,,,fee schedule,,,3344.48,,,fee schedule,,,3551.81,,,fee schedule,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,3398.86,,,fee schedule,,,,,,,,,3398.86,,,fee schedule,,,,,,,,
EXC BLES S/N/EX G; > 4.0CM,2800000032,CDM,761,RC,11426,CPT,11,EAPG,,,,outpatient,facility,,,4935.57,4935.57,2052.64,3009.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3009.17,,,fee schedule,,,2052.64,,,fee schedule,,,2675.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,2052.64,,,fee schedule,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC FACE-MM B9+MARG 0.5CM/<,2800000033,CDM,761,RC,11440,CPT,,,,,,inpatient,facility,,,1108.7,1108.7,88.7,1108.7,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,613.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1011.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,578.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,778.53,,,percent of total billed charges,,
EXC FACE-MM B9+MARG 0.5CM/<,2800000033,CDM,761,RC,11440,CPT,,,,,,outpatient,facility,,,1108.7,1108.7,77.22,1485.18,,647.48,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,750.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,851.48,,,percent of total billed charges,,,,,,,,,,,,,,,1403.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",1485.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,578.08,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,419.98,,,percent of total billed charges,,,574.2,,,percent of total billed charges,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",831.53,,,percent of total billed charges,,,1108.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,554.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,77.22,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC FACE-MM B9+MARG 0.5CM/<,2800000033,CDM,761,RC,11440,CPT,5071,APC,,,,outpatient,facility,,,1108.7,1108.7,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC FACE-MM B9+MARG 0.5CM/<,2800000033,CDM,761,RC,11440,CPT,9,EAPG,,,,outpatient,facility,,,1108.7,1108.7,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC FACE-MM B9+MARG 0.6-1 CM,2800000034,CDM,761,RC,11441,CPT,,,,,,inpatient,facility,,,1108.7,1108.7,88.7,1108.7,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,613.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1011.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,578.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,778.53,,,percent of total billed charges,,
EXC FACE-MM B9+MARG 0.6-1 CM,2800000034,CDM,761,RC,11441,CPT,,,,,,outpatient,facility,,,1108.7,1108.7,86.42,1485.18,,647.48,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,750.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,851.48,,,percent of total billed charges,,,,,,,,,,,,,,,1403.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",1485.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,578.08,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,419.98,,,percent of total billed charges,,,574.2,,,percent of total billed charges,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",831.53,,,percent of total billed charges,,,1108.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,554.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,86.42,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC FACE-MM B9+MARG 0.6-1 CM,2800000034,CDM,761,RC,11441,CPT,5071,APC,,,,outpatient,facility,,,1108.7,1108.7,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC FACE-MM B9+MARG 0.6-1 CM,2800000034,CDM,761,RC,11441,CPT,9,EAPG,,,,outpatient,facility,,,1108.7,1108.7,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC FACE-MM B9+MARG 1.1-2 CM,2800000035,CDM,761,RC,11442,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC FACE-MM B9+MARG 1.1-2 CM,2800000035,CDM,761,RC,11442,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,95.25,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,95.25,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC FACE-MM B9+MARG 1.1-2 CM,2800000035,CDM,761,RC,11442,CPT,5071,APC,,,,outpatient,facility,,,1821.6,1821.6,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC FACE-MM B9+MARG 1.1-2 CM,2800000035,CDM,761,RC,11442,CPT,9,EAPG,,,,outpatient,facility,,,1821.6,1821.6,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC FACE-MM B9+MARG 2.1-3 CM,2800000036,CDM,761,RC,11443,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC FACE-MM B9+MARG 2.1-3 CM,2800000036,CDM,761,RC,11443,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,106.64,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,2244.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,1924.13,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,106.64,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC FACE-MM B9+MARG 2.1-3 CM,2800000036,CDM,761,RC,11443,CPT,5072,APC,,,,outpatient,facility,,,1821.6,1821.6,1827.07,2745.34,,,,,,,,1950.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1912.27,,,fee schedule,,,,,,,,,1893.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1987.63,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,,,,,,,2745.34,,,fee schedule,,,,,,,,,,,,,,,1949.91,,,fee schedule,,,,,,,,,,,,,,,1827.07,,,fee schedule,,,2025.87,,,fee schedule,,,2020.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1950.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.22,,,fee schedule,,,1893.34,,,fee schedule,,,2010.72,,,fee schedule,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1924.13,,,fee schedule,,,,,,,,,1924.13,,,fee schedule,,,,,,,,
EXC FACE-MM B9+MARG 2.1-3 CM,2800000036,CDM,761,RC,11443,CPT,10,EAPG,,,,outpatient,facility,,,1821.6,1821.6,1234.87,1810.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1810.32,,,fee schedule,,,1234.87,,,fee schedule,,,1609.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC FACE-MM B9+MARG 3.1-4 CM,2800000037,CDM,761,RC,11444,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC FACE-MM B9+MARG 3.1-4 CM,2800000037,CDM,761,RC,11444,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,145.73,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,2244.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,1924.13,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,388.12,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC FACE-MM B9+MARG 3.1-4 CM,2800000037,CDM,761,RC,11444,CPT,5072,APC,,,,outpatient,facility,,,1821.6,1821.6,1827.07,2745.34,,,,,,,,1950.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1912.27,,,fee schedule,,,,,,,,,1893.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1987.63,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,,,,,,,2745.34,,,fee schedule,,,,,,,,,,,,,,,1949.91,,,fee schedule,,,,,,,,,,,,,,,1827.07,,,fee schedule,,,2025.87,,,fee schedule,,,2020.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1950.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.22,,,fee schedule,,,1893.34,,,fee schedule,,,2010.72,,,fee schedule,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1924.13,,,fee schedule,,,,,,,,,1924.13,,,fee schedule,,,,,,,,
EXC FACE-MM B9+MARG 3.1-4 CM,2800000037,CDM,761,RC,11444,CPT,10,EAPG,,,,outpatient,facility,,,1821.6,1821.6,1234.87,1810.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1810.32,,,fee schedule,,,1234.87,,,fee schedule,,,1609.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC TR-EXT MAL+MARG 0.5 < CM,2800000038,CDM,761,RC,11600,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC TR-EXT MAL+MARG 0.5 < CM,2800000038,CDM,761,RC,11600,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,98.92,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,98.92,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC TR-EXT MAL+MARG 0.5 < CM,2800000038,CDM,761,RC,11600,CPT,5071,APC,,,,outpatient,facility,,,1821.6,1821.6,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC TR-EXT MAL+MARG 0.5 < CM,2800000038,CDM,761,RC,11600,CPT,9,EAPG,,,,outpatient,facility,,,1821.6,1821.6,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC TR-EXT MAL+MARG 0.6-1 CM,2800000039,CDM,761,RC,11601,CPT,,,,,,inpatient,facility,,,1108.7,1108.7,88.7,1108.7,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,613.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1011.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,578.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,778.53,,,percent of total billed charges,,
EXC TR-EXT MAL+MARG 0.6-1 CM,2800000039,CDM,761,RC,11601,CPT,,,,,,outpatient,facility,,,1108.7,1108.7,88.7,1485.18,,647.48,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,750.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,851.48,,,percent of total billed charges,,,,,,,,,,,,,,,1403.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",1485.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,578.08,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,419.98,,,percent of total billed charges,,,574.2,,,percent of total billed charges,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",831.53,,,percent of total billed charges,,,1108.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,554.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,112.89,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC TR-EXT MAL+MARG 0.6-1 CM,2800000039,CDM,761,RC,11601,CPT,5071,APC,,,,outpatient,facility,,,1108.7,1108.7,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC TR-EXT MAL+MARG 0.6-1 CM,2800000039,CDM,761,RC,11601,CPT,9,EAPG,,,,outpatient,facility,,,1108.7,1108.7,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC TR-EXT MAL+MARG 1.1-2 CM,2800000040,CDM,761,RC,11602,CPT,,,,,,inpatient,facility,,,1108.7,1108.7,88.7,1108.7,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,613.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1011.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,578.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,778.53,,,percent of total billed charges,,
EXC TR-EXT MAL+MARG 1.1-2 CM,2800000040,CDM,761,RC,11602,CPT,,,,,,outpatient,facility,,,1108.7,1108.7,88.7,1485.18,,647.48,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,512.54,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,750.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,851.48,,,percent of total billed charges,,,,,,,,,,,,,,,1403.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",1485.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,578.08,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,419.98,,,percent of total billed charges,,,574.2,,,percent of total billed charges,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,474.47,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",831.53,,,percent of total billed charges,,,1108.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,554.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,122.46,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC TR-EXT MAL+MARG 1.1-2 CM,2800000040,CDM,761,RC,11602,CPT,5052,APC,,,,outpatient,facility,,,1108.7,1108.7,450.54,676.98,,,,,,,,480.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.55,,,fee schedule,,,,,,,,,466.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,490.12,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,,,,,,,676.98,,,fee schedule,,,,,,,,,,,,,,,480.82,,,fee schedule,,,,,,,,,,,,,,,450.54,,,fee schedule,,,499.56,,,fee schedule,,,498.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,493.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,480.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.39,,,fee schedule,,,466.88,,,fee schedule,,,495.82,,,fee schedule,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,474.47,,,fee schedule,,,,,,,,,474.47,,,fee schedule,,,,,,,,
EXC TR-EXT MAL+MARG 1.1-2 CM,2800000040,CDM,761,RC,11602,CPT,9,EAPG,,,,outpatient,facility,,,1108.7,1108.7,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC TR-EXT MAL+MARG 2.1-3 CM,2800000041,CDM,761,RC,11603,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC TR-EXT MAL+MARG 2.1-3 CM,2800000041,CDM,761,RC,11603,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,130.91,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,130.91,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC TR-EXT MAL+MARG 2.1-3 CM,2800000041,CDM,761,RC,11603,CPT,5071,APC,,,,outpatient,facility,,,1821.6,1821.6,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC TR-EXT MAL+MARG 2.1-3 CM,2800000041,CDM,761,RC,11603,CPT,9,EAPG,,,,outpatient,facility,,,1821.6,1821.6,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC TR-EXT MAL+MARG 3.1-4 CM,2800000042,CDM,761,RC,11604,CPT,,,,,,inpatient,facility,,,4367.96,4367.96,349.44,4367.96,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3931.16,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2418.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3985.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,2277.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.44,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3067.18,,,percent of total billed charges,,
EXC TR-EXT MAL+MARG 3.1-4 CM,2800000042,CDM,761,RC,11604,CPT,,,,,,outpatient,facility,,,4367.96,4367.96,319.69,4428.39,,2550.89,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3931.16,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2957.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3354.59,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2277.45,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1250,,,case rate,,,1654.58,,,percent of total billed charges,,,2262.17,,,percent of total billed charges,,,,,,,,,,,,,,,873.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3873.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",1726.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,349.44,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,3321.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",2878.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",3275.97,,,percent of total billed charges,,,4367.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2183.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,388.12,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC TR-EXT MAL+MARG 3.1-4 CM,2800000042,CDM,761,RC,11604,CPT,5071,APC,,,,outpatient,facility,,,4367.96,4367.96,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC TR-EXT MAL+MARG 3.1-4 CM,2800000042,CDM,761,RC,11604,CPT,10,EAPG,,,,outpatient,facility,,,4367.96,4367.96,1234.87,1810.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1810.32,,,fee schedule,,,1234.87,,,fee schedule,,,1609.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC TR-EXT MAL+MARG > 4 CM,2800000043,CDM,761,RC,11606,CPT,,,,,,inpatient,facility,,,4367.96,4367.96,349.44,4367.96,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3931.16,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2418.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3985.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,2277.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.44,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3067.18,,,percent of total billed charges,,
EXC TR-EXT MAL+MARG > 4 CM,2800000043,CDM,761,RC,11606,CPT,,,,,,outpatient,facility,,,4367.96,4367.96,319.69,4428.39,,2550.89,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2244.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3931.16,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2957.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3354.59,,,percent of total billed charges,,,,,,,,,,,,,,,4129.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",4370.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2277.45,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1250,,,case rate,,,1654.58,,,percent of total billed charges,,,2262.17,,,percent of total billed charges,,,,,,,,,,,,,,,873.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3873.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",1726.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,349.44,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,1924.13,,,fee schedule,,,4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,3321.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",2878.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",3275.97,,,percent of total billed charges,,,4367.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2183.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,719.48,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC TR-EXT MAL+MARG > 4 CM,2800000043,CDM,761,RC,11606,CPT,5072,APC,,,,outpatient,facility,,,4367.96,4367.96,1827.07,2745.34,,,,,,,,1950.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1912.27,,,fee schedule,,,,,,,,,1893.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1987.63,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,,,,,,,2745.34,,,fee schedule,,,,,,,,,,,,,,,1949.91,,,fee schedule,,,,,,,,,,,,,,,1827.07,,,fee schedule,,,2025.87,,,fee schedule,,,2020.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1950.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.22,,,fee schedule,,,1893.34,,,fee schedule,,,2010.72,,,fee schedule,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1924.13,,,fee schedule,,,,,,,,,1924.13,,,fee schedule,,,,,,,,
EXC TR-EXT MAL+MARG > 4 CM,2800000043,CDM,761,RC,11606,CPT,11,EAPG,,,,outpatient,facility,,,4367.96,4367.96,2052.64,3009.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3009.17,,,fee schedule,,,2052.64,,,fee schedule,,,2675.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,2052.64,,,fee schedule,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC H-F-NK-SP MAL+MARG 0.5 <,2800000044,CDM,761,RC,11620,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC H-F-NK-SP MAL+MARG 0.5 <,2800000044,CDM,761,RC,11620,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,100.03,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,2244.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,1924.13,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,100.03,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC H-F-NK-SP MAL+MARG 0.5 <,2800000044,CDM,761,RC,11620,CPT,5072,APC,,,,outpatient,facility,,,1821.6,1821.6,1827.07,2745.34,,,,,,,,1950.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1912.27,,,fee schedule,,,,,,,,,1893.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1987.63,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,,,,,,,2745.34,,,fee schedule,,,,,,,,,,,,,,,1949.91,,,fee schedule,,,,,,,,,,,,,,,1827.07,,,fee schedule,,,2025.87,,,fee schedule,,,2020.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1950.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.22,,,fee schedule,,,1893.34,,,fee schedule,,,2010.72,,,fee schedule,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1924.13,,,fee schedule,,,,,,,,,1924.13,,,fee schedule,,,,,,,,
EXC H-F-NK-SP MAL+MARG 0.5 <,2800000044,CDM,761,RC,11620,CPT,10,EAPG,,,,outpatient,facility,,,1821.6,1821.6,1234.87,1810.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1810.32,,,fee schedule,,,1234.87,,,fee schedule,,,1609.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC S/N/H/F/G MAL+MRG 0.6-1,2800000045,CDM,761,RC,11621,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC S/N/H/F/G MAL+MRG 0.6-1,2800000045,CDM,761,RC,11621,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,114,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,114,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC S/N/H/F/G MAL+MRG 0.6-1,2800000045,CDM,761,RC,11621,CPT,5071,APC,,,,outpatient,facility,,,1821.6,1821.6,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC S/N/H/F/G MAL+MRG 0.6-1,2800000045,CDM,761,RC,11621,CPT,9,EAPG,,,,outpatient,facility,,,1821.6,1821.6,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC S/N/H/F/G MAL+MRG 1.1-2,2800000046,CDM,761,RC,11622,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC S/N/H/F/G MAL+MRG 1.1-2,2800000046,CDM,761,RC,11622,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,126.13,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,126.13,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC S/N/H/F/G MAL+MRG 1.1-2,2800000046,CDM,761,RC,11622,CPT,5071,APC,,,,outpatient,facility,,,1821.6,1821.6,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC S/N/H/F/G MAL+MRG 1.1-2,2800000046,CDM,761,RC,11622,CPT,9,EAPG,,,,outpatient,facility,,,1821.6,1821.6,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC S/N/H/F/G MAL+MRG 2.1-3,2800000047,CDM,761,RC,11623,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC S/N/H/F/G MAL+MRG 2.1-3,2800000047,CDM,761,RC,11623,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,136.79,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,2244.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,1924.13,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,136.79,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC S/N/H/F/G MAL+MRG 2.1-3,2800000047,CDM,761,RC,11623,CPT,5072,APC,,,,outpatient,facility,,,1821.6,1821.6,1827.07,2745.34,,,,,,,,1950.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1912.27,,,fee schedule,,,,,,,,,1893.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1987.63,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,,,,,,,2745.34,,,fee schedule,,,,,,,,,,,,,,,1949.91,,,fee schedule,,,,,,,,,,,,,,,1827.07,,,fee schedule,,,2025.87,,,fee schedule,,,2020.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1950.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.22,,,fee schedule,,,1893.34,,,fee schedule,,,2010.72,,,fee schedule,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1924.13,,,fee schedule,,,,,,,,,1924.13,,,fee schedule,,,,,,,,
EXC S/N/H/F/G MAL+MRG 2.1-3,2800000047,CDM,761,RC,11623,CPT,10,EAPG,,,,outpatient,facility,,,1821.6,1821.6,1234.87,1810.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1810.32,,,fee schedule,,,1234.87,,,fee schedule,,,1609.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC S/N/H/F/G MAL+MRG > 4 CM,2800000048,CDM,761,RC,11626,CPT,,,,,,inpatient,facility,,,4935.57,4935.57,394.85,4935.57,,,,,,,,,,,,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4442.01,,,percent of total billed charges,,,,,,,,,4935.57,,,percent of total billed charges,,,2732.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4503.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,4935.57,,,percent of total billed charges,,,2573.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,987.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,394.85,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3465.76,,,percent of total billed charges,,
EXC S/N/H/F/G MAL+MRG > 4 CM,2800000048,CDM,761,RC,11626,CPT,,,,,,outpatient,facility,,,4935.57,4935.57,319.69,4935.57,,2882.37,,,percent of total billed charges,,,,,,,,,4935.57,,,percent of total billed charges,,,3881.03,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,4318.9,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,4318.9,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,4442.01,,,percent of total billed charges,,,,,,,,,4935.57,,,percent of total billed charges,,,3342.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3790.52,,,percent of total billed charges,,,,,,,,,,,,,,,4129.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",4370.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2573.41,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1250,,,case rate,,,1869.59,,,percent of total billed charges,,,2556.13,,,percent of total billed charges,,,,,,,,,,,,,,,987.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3873.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",1726.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,394.85,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,4935.57,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,,,,,,,3398.86,,,fee schedule,,,4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,3321.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",2878.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",3701.68,,,percent of total billed charges,,,4935.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4935.57,,,percent of total billed charges,,,4935.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2467.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,943.36,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC S/N/H/F/G MAL+MRG > 4 CM,2800000048,CDM,761,RC,11626,CPT,5073,APC,,,,outpatient,facility,,,4935.57,4935.57,3227.42,4849.5,,,,,,,,3444.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3377.92,,,fee schedule,,,,,,,,,3344.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,3511.02,,,fee schedule,,,3511.7,,,fee schedule,,,,,,,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,3511.7,,,fee schedule,,,,,,,,,,,,,,,4849.5,,,fee schedule,,,,,,,,,,,,,,,3444.41,,,fee schedule,,,,,,,,,,,,,,,3227.42,,,fee schedule,,,3578.59,,,fee schedule,,,3568.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3534.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4180.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,3444.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3743.97,,,fee schedule,,,3344.48,,,fee schedule,,,3551.81,,,fee schedule,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,3398.86,,,fee schedule,,,,,,,,,3398.86,,,fee schedule,,,,,,,,
EXC S/N/H/F/G MAL+MRG > 4 CM,2800000048,CDM,761,RC,11626,CPT,11,EAPG,,,,outpatient,facility,,,4935.57,4935.57,2052.64,3009.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3009.17,,,fee schedule,,,2052.64,,,fee schedule,,,2675.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,2052.64,,,fee schedule,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2052.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC F/E/E/N/L MAL+MRG 0.5CM<,2800000049,CDM,761,RC,11640,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC F/E/E/N/L MAL+MRG 0.5CM<,2800000049,CDM,761,RC,11640,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,104.8,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,104.8,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC F/E/E/N/L MAL+MRG 0.5CM<,2800000049,CDM,761,RC,11640,CPT,5071,APC,,,,outpatient,facility,,,1821.6,1821.6,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC F/E/E/N/L MAL+MRG 0.5CM<,2800000049,CDM,761,RC,11640,CPT,9,EAPG,,,,outpatient,facility,,,1821.6,1821.6,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC F/E/E/N/L MAL+MRG 0.6-1,2800000050,CDM,761,RC,11641,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC F/E/E/N/L MAL+MRG 0.6-1,2800000050,CDM,761,RC,11641,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,122.46,1821.6,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,1403.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",1485.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,122.46,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC F/E/E/N/L MAL+MRG 0.6-1,2800000050,CDM,761,RC,11641,CPT,5071,APC,,,,outpatient,facility,,,1821.6,1821.6,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC F/E/E/N/L MAL+MRG 0.6-1,2800000050,CDM,761,RC,11641,CPT,9,EAPG,,,,outpatient,facility,,,1821.6,1821.6,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC F/E/E/N/L MAL+MRG 1.1-2,2800000051,CDM,761,RC,11642,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC F/E/E/N/L MAL+MRG 1.1-2,2800000051,CDM,761,RC,11642,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,136.79,1821.6,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,1403.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",1485.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,136.79,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC F/E/E/N/L MAL+MRG 1.1-2,2800000051,CDM,761,RC,11642,CPT,5071,APC,,,,outpatient,facility,,,1821.6,1821.6,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
EXC F/E/E/N/L MAL+MRG 1.1-2,2800000051,CDM,761,RC,11642,CPT,9,EAPG,,,,outpatient,facility,,,1821.6,1821.6,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC F/E/E/N/L MAL+MRG 2.1-3,2800000052,CDM,761,RC,11643,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
EXC F/E/E/N/L MAL+MRG 2.1-3,2800000052,CDM,761,RC,11643,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,145.73,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,2244.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,1924.13,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,148.57,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC F/E/E/N/L MAL+MRG 2.1-3,2800000052,CDM,761,RC,11643,CPT,5072,APC,,,,outpatient,facility,,,1821.6,1821.6,1827.07,2745.34,,,,,,,,1950.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1912.27,,,fee schedule,,,,,,,,,1893.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1987.63,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,,,,,,,2745.34,,,fee schedule,,,,,,,,,,,,,,,1949.91,,,fee schedule,,,,,,,,,,,,,,,1827.07,,,fee schedule,,,2025.87,,,fee schedule,,,2020.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1950.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.22,,,fee schedule,,,1893.34,,,fee schedule,,,2010.72,,,fee schedule,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1924.13,,,fee schedule,,,,,,,,,1924.13,,,fee schedule,,,,,,,,
EXC F/E/E/N/L MAL+MRG 2.1-3,2800000052,CDM,761,RC,11643,CPT,10,EAPG,,,,outpatient,facility,,,1821.6,1821.6,1234.87,1810.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1810.32,,,fee schedule,,,1234.87,,,fee schedule,,,1609.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REMOVAL OF NAIL BED,2800000053,CDM,761,RC,11750,CPT,,,,,,inpatient,facility,,,1164.14,1164.14,93.13,1164.14,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1047.73,,,percent of total billed charges,,,,,,,,,1164.14,,,percent of total billed charges,,,644.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1062.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,606.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.13,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,817.46,,,percent of total billed charges,,
REMOVAL OF NAIL BED,2800000053,CDM,761,RC,11750,CPT,,,,,,outpatient,facility,,,1164.14,1164.14,93.13,1185.37,,679.86,,,percent of total billed charges,,,,,,,,,1164.14,,,percent of total billed charges,,,512.54,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1047.73,,,percent of total billed charges,,,,,,,,,1164.14,,,percent of total billed charges,,,788.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.06,,,percent of total billed charges,,,,,,,,,,,,,,,666.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",705.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,606.98,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,440.98,,,percent of total billed charges,,,602.91,,,percent of total billed charges,,,,,,,,,,,,,,,232.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,93.13,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,,,,,,,474.47,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",873.11,,,percent of total billed charges,,,1164.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1164.14,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,582.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,94.13,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
REMOVAL OF NAIL BED,2800000053,CDM,761,RC,11750,CPT,5052,APC,,,,outpatient,facility,,,1164.14,1164.14,450.54,676.98,,,,,,,,480.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.55,,,fee schedule,,,,,,,,,466.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,490.12,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,,,,,,,676.98,,,fee schedule,,,,,,,,,,,,,,,480.82,,,fee schedule,,,,,,,,,,,,,,,450.54,,,fee schedule,,,499.56,,,fee schedule,,,498.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,493.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,480.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.39,,,fee schedule,,,466.88,,,fee schedule,,,495.82,,,fee schedule,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,474.47,,,fee schedule,,,,,,,,,474.47,,,fee schedule,,,,,,,,
REMOVAL OF NAIL BED,2800000053,CDM,761,RC,11750,CPT,9,EAPG,,,,outpatient,facility,,,1164.14,1164.14,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE EXC NAIL FOLD,2800000054,CDM,761,RC,11765,CPT,,,,,,inpatient,facility,,,491.47,491.47,39.32,491.47,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.32,,,percent of total billed charges,,,,,,,,,491.47,,,percent of total billed charges,,,272.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,448.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,256.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.32,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.11,,,percent of total billed charges,,
WEDGE EXC NAIL FOLD,2800000054,CDM,761,RC,11765,CPT,,,,,,outpatient,facility,,,491.47,491.47,39.32,618.77,,287.02,,,percent of total billed charges,,,,,,,,,491.47,,,percent of total billed charges,,,512.54,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,442.32,,,percent of total billed charges,,,,,,,,,491.47,,,percent of total billed charges,,,332.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.45,,,percent of total billed charges,,,,,,,,,,,,,,,344.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",364.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,256.25,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.52,,,percent of total billed charges,,,186.17,,,percent of total billed charges,,,254.53,,,percent of total billed charges,,,,,,,,,,,,,,,98.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,497.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",221.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,39.32,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,474.47,,,fee schedule,,,568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,426.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",369.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",368.6,,,percent of total billed charges,,,491.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,491.47,,,percent of total billed charges,,,491.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,65.22,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
WEDGE EXC NAIL FOLD,2800000054,CDM,761,RC,11765,CPT,5052,APC,,,,outpatient,facility,,,491.47,491.47,450.54,676.98,,,,,,,,480.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.55,,,fee schedule,,,,,,,,,466.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,490.12,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,,,,,,,676.98,,,fee schedule,,,,,,,,,,,,,,,480.82,,,fee schedule,,,,,,,,,,,,,,,450.54,,,fee schedule,,,499.56,,,fee schedule,,,498.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,493.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,480.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.39,,,fee schedule,,,466.88,,,fee schedule,,,495.82,,,fee schedule,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,474.47,,,fee schedule,,,,,,,,,474.47,,,fee schedule,,,,,,,,
WEDGE EXC NAIL FOLD,2800000054,CDM,761,RC,11765,CPT,5,EAPG,,,,outpatient,facility,,,491.47,491.47,107.25,157.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.23,,,fee schedule,,,107.25,,,fee schedule,,,139.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.25,,,fee schedule,,,107.25,,,fee schedule,,,107.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,107.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC PILONID CYST; SMPL,2800000055,CDM,761,RC,11770,CPT,,,,,,inpatient,facility,,,6409.39,6409.39,512.75,6409.39,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5768.45,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,3548.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5847.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,3341.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1281.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.75,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4500.67,,,percent of total billed charges,,
EXC PILONID CYST; SMPL,2800000055,CDM,761,RC,11770,CPT,,,,,,outpatient,facility,,,6409.39,6409.39,319.69,6930.49,,3743.08,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,3881.03,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,4318.9,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,4318.9,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5768.45,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,4340.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4922.41,,,percent of total billed charges,,,,,,,,,,,,,,,4129.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",4370.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3341.86,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1600,,,case rate,,,2427.88,,,percent of total billed charges,,,3319.42,,,percent of total billed charges,,,,,,,,,,,,,,,1281.88,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6061.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",2702.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,512.75,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,3398.86,,,fee schedule,,,6930.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,5197.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",6930.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",4504.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",4807.04,,,percent of total billed charges,,,6409.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,943.36,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC PILONID CYST; SMPL,2800000055,CDM,761,RC,11770,CPT,5073,APC,,,,outpatient,facility,,,6409.39,6409.39,3227.42,4849.5,,,,,,,,3444.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3377.92,,,fee schedule,,,,,,,,,3344.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,3511.02,,,fee schedule,,,3511.7,,,fee schedule,,,,,,,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,3511.7,,,fee schedule,,,,,,,,,,,,,,,4849.5,,,fee schedule,,,,,,,,,,,,,,,3444.41,,,fee schedule,,,,,,,,,,,,,,,3227.42,,,fee schedule,,,3578.59,,,fee schedule,,,3568.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3534.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4180.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,3444.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3743.97,,,fee schedule,,,3344.48,,,fee schedule,,,3551.81,,,fee schedule,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,3398.86,,,fee schedule,,,,,,,,,3398.86,,,fee schedule,,,,,,,,
EXC PILONID CYST; SMPL,2800000055,CDM,761,RC,11770,CPT,10,EAPG,,,,outpatient,facility,,,6409.39,6409.39,1234.87,1810.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1810.32,,,fee schedule,,,1234.87,,,fee schedule,,,1609.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1234.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SREP F/E/N/L/MM; 2.5CM/<,2800000056,CDM,761,RC,12011,CPT,,,,,,inpatient,facility,,,1897.43,1897.43,151.79,1897.43,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1707.69,,,percent of total billed charges,,,,,,,,,1897.43,,,percent of total billed charges,,,1050.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1731.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,989.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,379.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.79,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1332.38,,,percent of total billed charges,,
SREP F/E/N/L/MM; 2.5CM/<,2800000056,CDM,761,RC,12011,CPT,,,,,,outpatient,facility,,,1897.43,1897.43,57.17,1897.43,,1108.1,,,percent of total billed charges,,,,,,,,,1897.43,,,percent of total billed charges,,,287.94,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1707.69,,,percent of total billed charges,,,,,,,,,1897.43,,,percent of total billed charges,,,1284.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1457.23,,,percent of total billed charges,,,,,,,,,,,,,,,344.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",364.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,989.32,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1442.05,,,percent of total billed charges,,,718.75,,,percent of total billed charges,,,982.68,,,percent of total billed charges,,,,,,,,,,,,,,,379.49,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,151.79,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,,,,,,,235.97,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1423.07,,,percent of total billed charges,,,1897.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1897.43,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,57.17,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
SREP F/E/N/L/MM; 2.5CM/<,2800000056,CDM,761,RC,12011,CPT,5051,APC,,,,outpatient,facility,,,1897.43,1897.43,224.06,336.68,,,,,,,,239.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.51,,,fee schedule,,,,,,,,,232.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,243.76,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,,,,,,,336.68,,,fee schedule,,,,,,,,,,,,,,,239.13,,,fee schedule,,,,,,,,,,,,,,,224.06,,,fee schedule,,,248.44,,,fee schedule,,,247.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,245.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,239.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.78,,,fee schedule,,,232.19,,,fee schedule,,,246.59,,,fee schedule,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,235.97,,,fee schedule,,,,,,,,,235.97,,,fee schedule,,,,,,,,
SREP F/E/N/L/MM; 2.5CM/<,2800000056,CDM,761,RC,12011,CPT,16,EAPG,,,,outpatient,facility,,,1897.43,1897.43,323.52,474.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,474.28,,,fee schedule,,,323.52,,,fee schedule,,,421.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.52,,,fee schedule,,,323.52,,,fee schedule,,,323.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,323.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INTMD WND REPAIR S/A/T/EXT,2800000057,CDM,761,RC,12032,CPT,,,,,,inpatient,facility,,,1164.14,1164.14,93.13,1164.14,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1047.73,,,percent of total billed charges,,,,,,,,,1164.14,,,percent of total billed charges,,,644.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1062.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,606.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.13,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,817.46,,,percent of total billed charges,,
INTMD WND REPAIR S/A/T/EXT,2800000057,CDM,761,RC,12032,CPT,,,,,,outpatient,facility,,,1164.14,1164.14,93.13,1185.37,,679.86,,,percent of total billed charges,,,,,,,,,1164.14,,,percent of total billed charges,,,512.54,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,570.36,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1047.73,,,percent of total billed charges,,,,,,,,,1164.14,,,percent of total billed charges,,,788.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.06,,,percent of total billed charges,,,,,,,,,,,,,,,658.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",696.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,606.98,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,884.75,,,percent of total billed charges,,,440.98,,,percent of total billed charges,,,602.91,,,percent of total billed charges,,,,,,,,,,,,,,,232.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,93.13,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,,,,,,,474.47,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",873.11,,,percent of total billed charges,,,1164.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1164.14,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,582.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,94.07,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
INTMD WND REPAIR S/A/T/EXT,2800000057,CDM,761,RC,12032,CPT,5052,APC,,,,outpatient,facility,,,1164.14,1164.14,450.54,676.98,,,,,,,,480.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.55,,,fee schedule,,,,,,,,,466.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,490.12,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,490.22,,,fee schedule,,,,,,,,,,,,,,,676.98,,,fee schedule,,,,,,,,,,,,,,,480.82,,,fee schedule,,,,,,,,,,,,,,,450.54,,,fee schedule,,,499.56,,,fee schedule,,,498.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,493.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,583.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,,,,,,,,,,,,,466.88,,,fee schedule,,,480.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.39,,,fee schedule,,,466.88,,,fee schedule,,,495.82,,,fee schedule,,,466.88,,,fee schedule,,,466.88,,,fee schedule,,,474.47,,,fee schedule,,,,,,,,,474.47,,,fee schedule,,,,,,,,
INTMD WND REPAIR S/A/T/EXT,2800000057,CDM,761,RC,12032,CPT,17,EAPG,,,,outpatient,facility,,,1164.14,1164.14,550.82,807.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,807.5,,,fee schedule,,,550.82,,,fee schedule,,,717.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550.82,,,fee schedule,,,550.82,,,fee schedule,,,550.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,550.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DESTRUCT B9 LESION 1-14,2800000058,CDM,761,RC,17110,CPT,,,,,,inpatient,facility,,,253.66,253.66,20.29,253.66,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,140.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,132.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.12,,,percent of total billed charges,,
DESTRUCT B9 LESION 1-14,2800000058,CDM,761,RC,17110,CPT,,,,,,outpatient,facility,,,253.66,253.66,20.29,618.77,,148.14,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,287.94,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,320.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,228.29,,,percent of total billed charges,,,,,,,,,253.66,,,percent of total billed charges,,,171.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.81,,,percent of total billed charges,,,,,,,,,,,,,,,344.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",364.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,132.26,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.78,,,percent of total billed charges,,,96.09,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,,,,,,,,,,,,,50.73,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,247.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",110.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,20.29,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,235.97,,,fee schedule,,,282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,212.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",183.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",190.25,,,percent of total billed charges,,,253.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,253.66,,,percent of total billed charges,,,253.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,35.44,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
DESTRUCT B9 LESION 1-14,2800000058,CDM,761,RC,17110,CPT,5051,APC,,,,outpatient,facility,,,253.66,253.66,224.06,336.68,,,,,,,,239.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.51,,,fee schedule,,,,,,,,,232.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,243.76,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,243.8,,,fee schedule,,,,,,,,,,,,,,,336.68,,,fee schedule,,,,,,,,,,,,,,,239.13,,,fee schedule,,,,,,,,,,,,,,,224.06,,,fee schedule,,,248.44,,,fee schedule,,,247.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,245.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,290.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,,,,,,,,,,,,,232.19,,,fee schedule,,,239.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.78,,,fee schedule,,,232.19,,,fee schedule,,,246.59,,,fee schedule,,,232.19,,,fee schedule,,,232.19,,,fee schedule,,,235.97,,,fee schedule,,,,,,,,,235.97,,,fee schedule,,,,,,,,
DESTRUCT B9 LESION 1-14,2800000058,CDM,761,RC,17110,CPT,3,EAPG,,,,outpatient,facility,,,253.66,253.66,274.27,402.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.08,,,fee schedule,,,274.27,,,fee schedule,,,357.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INJ TRIGGER POINT 1/2 MUSCL,2800000062,CDM,761,RC,20552,CPT,,,,,,inpatient,facility,,,642.69,642.69,51.42,642.69,,,,,,,,,,,,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.42,,,percent of total billed charges,,,,,,,,,642.69,,,percent of total billed charges,,,355.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,586.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,642.69,,,percent of total billed charges,,,335.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.42,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,451.3,,,percent of total billed charges,,
INJ TRIGGER POINT 1/2 MUSCL,2800000062,CDM,761,RC,20552,CPT,,,,,,outpatient,facility,,,642.69,642.69,23.9,691.42,,375.33,,,percent of total billed charges,,,,,,,,,642.69,,,percent of total billed charges,,,403.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,449.42,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,449.42,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,578.42,,,percent of total billed charges,,,,,,,,,642.69,,,percent of total billed charges,,,435.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,493.59,,,percent of total billed charges,,,,,,,,,,,,,,,653.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",691.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,335.1,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,488.44,,,percent of total billed charges,,,243.45,,,percent of total billed charges,,,332.85,,,percent of total billed charges,,,,,,,,,,,,,,,128.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,497.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",221.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,51.42,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,642.69,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,,,,,,,350.56,,,fee schedule,,,568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,426.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",369.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",482.02,,,percent of total billed charges,,,642.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,642.69,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,321.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,23.9,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
INJ TRIGGER POINT 1/2 MUSCL,2800000062,CDM,761,RC,20552,CPT,5441,APC,,,,outpatient,facility,,,642.69,642.69,332.88,500.18,,,,,,,,355.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,344.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.4,,,fee schedule,,,,,,,,,344.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,344.95,,,fee schedule,,,,,,,,,,,,,,,362.13,,,fee schedule,,,362.2,,,fee schedule,,,,,,,,,344.95,,,fee schedule,,,344.95,,,fee schedule,,,362.2,,,fee schedule,,,,,,,,,,,,,,,500.18,,,fee schedule,,,,,,,,,,,,,,,355.26,,,fee schedule,,,,,,,,,,,,,,,332.88,,,fee schedule,,,369.1,,,fee schedule,,,368.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.95,,,fee schedule,,,344.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,364.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,431.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,344.95,,,fee schedule,,,344.95,,,fee schedule,,,,,,,,,,,,,,,344.95,,,fee schedule,,,,,,,,,,,,,,,344.95,,,fee schedule,,,355.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,390.25,,,fee schedule,,,344.95,,,fee schedule,,,366.34,,,fee schedule,,,344.95,,,fee schedule,,,344.95,,,fee schedule,,,350.56,,,fee schedule,,,,,,,,,350.56,,,fee schedule,,,,,,,,
INJ TRIGGER POINT 1/2 MUSCL,2800000062,CDM,761,RC,20552,CPT,49,EAPG,,,,outpatient,facility,,,642.69,642.69,252.97,370.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.85,,,fee schedule,,,252.97,,,fee schedule,,,329.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,252.97,,,fee schedule,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC TNDN SHTH LES HND/FING,2800000067,CDM,761,RC,26160,CPT,,,,,,inpatient,facility,,,6409.39,6409.39,512.75,6409.39,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5768.45,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,3548.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5847.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,3341.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1281.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.75,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4500.67,,,percent of total billed charges,,
EXC TNDN SHTH LES HND/FING,2800000067,CDM,761,RC,26160,CPT,,,,,,outpatient,facility,,,6409.39,6409.39,319.69,6930.49,,3743.08,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,2143.18,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2384.99,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2384.99,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5768.45,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,4340.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4922.41,,,percent of total billed charges,,,,,,,,,,,,,,,4249.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",4496.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3341.86,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1600,,,case rate,,,2427.88,,,percent of total billed charges,,,3319.42,,,percent of total billed charges,,,,,,,,,,,,,,,1281.88,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6061.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",2702.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,512.75,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,1900.58,,,fee schedule,,,6930.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,5197.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",6930.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",4504.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",4807.04,,,percent of total billed charges,,,6409.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,735.73,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC TNDN SHTH LES HND/FING,2800000067,CDM,761,RC,26160,CPT,5112,APC,,,,outpatient,facility,,,6409.39,6409.39,1804.71,2711.75,,,,,,,,1926.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1870.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1888.87,,,fee schedule,,,,,,,,,1870.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1870.17,,,fee schedule,,,,,,,,,,,,,,,1963.3,,,fee schedule,,,1963.68,,,fee schedule,,,,,,,,,1870.17,,,fee schedule,,,1870.17,,,fee schedule,,,1963.68,,,fee schedule,,,,,,,,,,,,,,,2711.75,,,fee schedule,,,,,,,,,,,,,,,1926.05,,,fee schedule,,,,,,,,,,,,,,,1804.71,,,fee schedule,,,2001.08,,,fee schedule,,,1995.61,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1870.17,,,fee schedule,,,1870.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1976.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2337.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2337.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1870.17,,,fee schedule,,,1870.17,,,fee schedule,,,,,,,,,,,,,,,1870.17,,,fee schedule,,,,,,,,,,,,,,,1870.17,,,fee schedule,,,1926.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2117.66,,,fee schedule,,,1870.17,,,fee schedule,,,1986.11,,,fee schedule,,,1870.17,,,fee schedule,,,1870.17,,,fee schedule,,,1900.58,,,fee schedule,,,,,,,,,1900.58,,,fee schedule,,,,,,,,
EXC TNDN SHTH LES HND/FING,2800000067,CDM,761,RC,26160,CPT,33,EAPG,,,,outpatient,facility,,,6409.39,6409.39,2235.86,3277.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3277.77,,,fee schedule,,,2235.86,,,fee schedule,,,2914,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2235.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2235.86,,,fee schedule,,,2235.86,,,fee schedule,,,2235.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2235.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2235.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REMOVE LUNG CATHETER,2800000071,CDM,761,RC,32552,CPT,,,,,,inpatient,facility,,,2487.98,2487.98,199.04,2487.98,,,,,,,,,,,,,,2487.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2239.18,,,percent of total billed charges,,,,,,,,,2487.98,,,percent of total billed charges,,,1377.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2270.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2487.98,,,percent of total billed charges,,,,,,,,,,,,,,,2487.98,,,percent of total billed charges,,,1297.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,497.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.04,,,percent of total billed charges,,,2487.98,,,percent of total billed charges,,,2487.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2487.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1747.06,,,percent of total billed charges,,
REMOVE LUNG CATHETER,2800000071,CDM,761,RC,32552,CPT,,,,,,outpatient,facility,,,2487.98,2487.98,199.04,2487.98,,1452.98,,,percent of total billed charges,,,,,,,,,2487.98,,,percent of total billed charges,,,1011.77,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1125.92,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1125.92,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,2487.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2239.18,,,percent of total billed charges,,,,,,,,,2487.98,,,percent of total billed charges,,,1684.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1910.77,,,percent of total billed charges,,,,,,,,,,,,,,,1409.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",1491.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,2487.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1297.23,,,percent of total billed charges,,,2487.98,,,percent of total billed charges,,,2487.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890.86,,,percent of total billed charges,,,942.45,,,percent of total billed charges,,,1288.52,,,percent of total billed charges,,,,,,,,,,,,,,,497.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,199.04,,,percent of total billed charges,,,2487.98,,,percent of total billed charges,,,2487.98,,,percent of total billed charges,,,,,,,,,,,,,,,2487.98,,,percent of total billed charges,,,2487.98,,,percent of total billed charges,,,,,,,,,734.22,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1865.99,,,percent of total billed charges,,,2487.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2487.98,,,percent of total billed charges,,,2487.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1243.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1747.06,,,percent of total billed charges,,
REMOVE LUNG CATHETER,2800000071,CDM,761,RC,32552,CPT,5181,APC,,,,outpatient,facility,,,2487.98,2487.98,697.18,1047.58,,,,,,,,744.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,722.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,729.69,,,fee schedule,,,,,,,,,722.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,722.47,,,fee schedule,,,,,,,,,,,,,,,758.45,,,fee schedule,,,758.59,,,fee schedule,,,,,,,,,722.47,,,fee schedule,,,722.47,,,fee schedule,,,758.59,,,fee schedule,,,,,,,,,,,,,,,1047.58,,,fee schedule,,,,,,,,,,,,,,,744.06,,,fee schedule,,,,,,,,,,,,,,,697.18,,,fee schedule,,,773.04,,,fee schedule,,,770.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.47,,,fee schedule,,,722.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,763.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,903.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,722.47,,,fee schedule,,,722.47,,,fee schedule,,,,,,,,,,,,,,,722.47,,,fee schedule,,,,,,,,,,,,,,,722.47,,,fee schedule,,,744.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,827.73,,,fee schedule,,,722.47,,,fee schedule,,,767.26,,,fee schedule,,,722.47,,,fee schedule,,,722.47,,,fee schedule,,,734.22,,,fee schedule,,,,,,,,,734.22,,,fee schedule,,,,,,,,
REMOVE LUNG CATHETER,2800000071,CDM,761,RC,32552,CPT,68,EAPG,,,,outpatient,facility,,,2487.98,2487.98,983.99,1442.53,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1442.53,,,fee schedule,,,983.99,,,fee schedule,,,1282.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,983.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,983.99,,,fee schedule,,,983.99,,,fee schedule,,,983.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,983.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,983.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROUTINE VENIPUNCTURE,2800000072,CDM,300,RC,36415,CPT,,,,,,inpatient,facility,,,17.44,17.44,1.4,17.44,,,,,,,,,,,,,,17.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.7,,,percent of total billed charges,,,,,,,,,17.44,,,percent of total billed charges,,,9.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.44,,,percent of total billed charges,,,,,,,,,,,,,,,17.44,,,percent of total billed charges,,,9.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,17.44,,,percent of total billed charges,,,17.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.25,,,percent of total billed charges,,
ROUTINE VENIPUNCTURE,2800000072,CDM,300,RC,36415,CPT,,,,,,outpatient,facility,,,17.44,17.44,1.4,618.77,,,,,,,service not payable,9.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,17.44,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,8.91,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,17.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9,,,fee schedule,,,,,,,,service not payable,8.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,service not payable,3,,,fee schedule,,,8.91,,,fee schedule,,,17.44,,,percent of total billed charges,,,11.81,,,percent of total billed charges,,,9.35,,,fee schedule,,,9.36,,,fee schedule,,,,,,,,,8.91,,,fee schedule,,,8.91,,,fee schedule,,,9.36,,,fee schedule,,,13.39,,,percent of total billed charges,,,,,,,,,12.92,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,9.17,,,fee schedule,,,618.77,,,per diem,,,17.44,,,percent of total billed charges,,,8.6,,,fee schedule,,,9.53,,,fee schedule,,,9.54,,,fee schedule,,,9.09,,,percent of total billed charges,,,17.44,,,percent of total billed charges,,,17.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.91,,,fee schedule,,,8.91,,,fee schedule,,,13.25,,,percent of total billed charges,,,6.61,,,percent of total billed charges,,,9.03,,,percent of total billed charges,,,,,,,,,9.45,,,fee schedule,,,3.49,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,11.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.4,,,percent of total billed charges,,,17.44,,,percent of total billed charges,,,17.44,,,percent of total billed charges,,,8.91,,,fee schedule,,,8.91,,,fee schedule,,,17.44,,,percent of total billed charges,,,17.44,,,percent of total billed charges,,,8.91,,,fee schedule,,,8.83,,,fee schedule,,,,,,,,service not payable,8.91,,,fee schedule,,,9.18,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,6.1,,,fee schedule,,,17.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,17.44,,,percent of total billed charges,,,17.44,,,percent of total billed charges,,,9.09,,,fee schedule,,,8.91,,,fee schedule,,,9.5,,,fee schedule,,,8.91,,,fee schedule,,,8.91,,,fee schedule,,,9.09,,,fee schedule,,,8.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,9.09,,,fee schedule,,,12.25,,,percent of total billed charges,,
ROUTINE VENIPUNCTURE,2800000072,CDM,300,RC,36415,CPT,999,EAPG,,,,outpatient,facility,,,17.44,17.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRANSFUSION BLOOD/BLOOD COMP,2800000073,CDM,391,RC,36430,CPT,,,,,,inpatient,facility,,,1296.28,1296.28,103.7,1296.28,,,,,,,,,,,,,,1296.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1166.65,,,percent of total billed charges,,,,,,,,,1296.28,,,percent of total billed charges,,,717.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1296.28,,,percent of total billed charges,,,,,,,,,,,,,,,1296.28,,,percent of total billed charges,,,675.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.7,,,percent of total billed charges,,,1296.28,,,percent of total billed charges,,,1296.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1296.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.25,,,percent of total billed charges,,
TRANSFUSION BLOOD/BLOOD COMP,2800000073,CDM,391,RC,36430,CPT,,,,,,outpatient,facility,,,1296.28,1296.28,103.7,1296.28,,757.03,,,percent of total billed charges,,,,,,,,,1296.28,,,percent of total billed charges,,,624.84,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,695.34,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,695.34,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1296.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1166.65,,,percent of total billed charges,,,,,,,,,1296.28,,,percent of total billed charges,,,877.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,995.54,,,percent of total billed charges,,,,,,,,,,,,,,,1019.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",1078.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1296.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,675.88,,,percent of total billed charges,,,1296.28,,,percent of total billed charges,,,1296.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,985.17,,,percent of total billed charges,,,491.03,,,percent of total billed charges,,,671.34,,,percent of total billed charges,,,,,,,,,,,,,,,259.26,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1119.77,,,fee schedule,,,499.25,,,fee schedule,,,,,,,,,,,,,,,103.7,,,percent of total billed charges,,,1296.28,,,percent of total billed charges,,,1296.28,,,percent of total billed charges,,,,,,,,,,,,,,,1296.28,,,percent of total billed charges,,,1296.28,,,percent of total billed charges,,,,,,,,,519.18,,,fee schedule,,,1100.59,,,fee schedule,,,,,,,,,,,,,,,967.83,,,fee schedule,,,1290.44,,,fee schedule,,,715.38,,,fee schedule,,,972.21,,,percent of total billed charges,,,1296.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1296.28,,,percent of total billed charges,,,1296.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,648.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,910.25,,,percent of total billed charges,,
TRANSFUSION BLOOD/BLOOD COMP,2800000073,CDM,391,RC,36430,CPT,5241,APC,,,,outpatient,facility,,,1296.28,1296.28,492.99,740.76,,,,,,,,526.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,510.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,515.98,,,fee schedule,,,,,,,,,510.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,510.87,,,fee schedule,,,,,,,,,,,,,,,536.31,,,fee schedule,,,536.41,,,fee schedule,,,,,,,,,510.87,,,fee schedule,,,510.87,,,fee schedule,,,536.41,,,fee schedule,,,,,,,,,,,,,,,740.76,,,fee schedule,,,,,,,,,,,,,,,526.14,,,fee schedule,,,,,,,,,,,,,,,492.99,,,fee schedule,,,546.63,,,fee schedule,,,545.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,510.87,,,fee schedule,,,510.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,539.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,638.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,638.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,510.87,,,fee schedule,,,510.87,,,fee schedule,,,,,,,,,,,,,,,510.87,,,fee schedule,,,,,,,,,,,,,,,510.87,,,fee schedule,,,526.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,571.98,,,fee schedule,,,510.87,,,fee schedule,,,542.54,,,fee schedule,,,510.87,,,fee schedule,,,510.87,,,fee schedule,,,519.18,,,fee schedule,,,,,,,,,519.18,,,fee schedule,,,,,,,,
TRANSFUSION BLOOD/BLOOD COMP,2800000073,CDM,391,RC,36430,CPT,113,EAPG,,,,outpatient,facility,,,1296.28,1296.28,520.35,762.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,762.83,,,fee schedule,,,520.35,,,fee schedule,,,678.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,520.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,520.35,,,fee schedule,,,520.35,,,fee schedule,,,520.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,520.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,520.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VENOUS SELECT ORGAN BLD SAMPL,2800000074,CDM,761,RC,36500,CPT,,,,,,inpatient,facility,,,2280.56,2280.56,182.44,2280.56,,,,,,,,,,,,,,2280.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2052.5,,,percent of total billed charges,,,,,,,,,2280.56,,,percent of total billed charges,,,1262.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2080.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2280.56,,,percent of total billed charges,,,,,,,,,,,,,,,2280.56,,,percent of total billed charges,,,1189.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,456.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.44,,,percent of total billed charges,,,2280.56,,,percent of total billed charges,,,2280.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2280.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1601.41,,,percent of total billed charges,,
VENOUS SELECT ORGAN BLD SAMPL,2800000074,CDM,761,RC,36500,CPT,,,,,,outpatient,facility,,,2280.56,2280.56,182.44,2280.56,,1331.85,,,percent of total billed charges,,,444.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,2280.56,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,2280.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,834.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,2052.5,,,percent of total billed charges,,,,,,,,,2280.56,,,percent of total billed charges,,,1544.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1751.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,2280.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1189.08,,,percent of total billed charges,,,2280.56,,,percent of total billed charges,,,2280.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1733.23,,,percent of total billed charges,,,863.88,,,percent of total billed charges,,,1181.1,,,percent of total billed charges,,,,,,,,,,,,,,,456.11,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,2280.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2280.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,182.44,,,percent of total billed charges,,,2280.56,,,percent of total billed charges,,,2280.56,,,percent of total billed charges,,,,,,,,,,,,,,,2280.56,,,percent of total billed charges,,,2280.56,,,percent of total billed charges,,,,,,,,,2280.56,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1710.42,,,percent of total billed charges,,,2280.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,2280.56,,,percent of total billed charges,,,2280.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1140.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1601.41,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
VENOUS SELECT ORGAN BLD SAMPL,2800000074,CDM,761,RC,36500,CPT,423,EAPG,,,,outpatient,facility,,,2280.56,2280.56,616.82,904.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,904.26,,,fee schedule,,,616.82,,,fee schedule,,,803.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,616.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,616.82,,,fee schedule,,,616.82,,,fee schedule,,,616.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,616.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,616.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REMOVE TNL CV CATH,2800000076,CDM,761,RC,36589,CPT,,,,,,inpatient,facility,,,1325.85,1325.85,106.07,1325.85,,,,,,,,,,,,,,1325.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1193.26,,,percent of total billed charges,,,,,,,,,1325.85,,,percent of total billed charges,,,733.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1209.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1325.85,,,percent of total billed charges,,,,,,,,,,,,,,,1325.85,,,percent of total billed charges,,,691.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.07,,,percent of total billed charges,,,1325.85,,,percent of total billed charges,,,1325.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1325.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,931.01,,,percent of total billed charges,,
REMOVE TNL CV CATH,2800000076,CDM,761,RC,36589,CPT,,,,,,outpatient,facility,,,1325.85,1325.85,106.07,1491.94,,774.3,,,percent of total billed charges,,,,,,,,,1325.85,,,percent of total billed charges,,,1011.77,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1125.92,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1125.92,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1325.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1193.26,,,percent of total billed charges,,,,,,,,,1325.85,,,percent of total billed charges,,,897.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,1409.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",1491.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1325.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,691.3,,,percent of total billed charges,,,1325.85,,,percent of total billed charges,,,1325.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,502.23,,,percent of total billed charges,,,686.66,,,percent of total billed charges,,,,,,,,,,,,,,,265.17,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,106.07,,,percent of total billed charges,,,1325.85,,,percent of total billed charges,,,1325.85,,,percent of total billed charges,,,,,,,,,,,,,,,1325.85,,,percent of total billed charges,,,1325.85,,,percent of total billed charges,,,,,,,,,734.22,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",994.39,,,percent of total billed charges,,,1325.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1325.85,,,percent of total billed charges,,,1325.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,662.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,253,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
REMOVE TNL CV CATH,2800000076,CDM,761,RC,36589,CPT,5181,APC,,,,outpatient,facility,,,1325.85,1325.85,697.18,1047.58,,,,,,,,744.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,722.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,729.69,,,fee schedule,,,,,,,,,722.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,722.47,,,fee schedule,,,,,,,,,,,,,,,758.45,,,fee schedule,,,758.59,,,fee schedule,,,,,,,,,722.47,,,fee schedule,,,722.47,,,fee schedule,,,758.59,,,fee schedule,,,,,,,,,,,,,,,1047.58,,,fee schedule,,,,,,,,,,,,,,,744.06,,,fee schedule,,,,,,,,,,,,,,,697.18,,,fee schedule,,,773.04,,,fee schedule,,,770.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.47,,,fee schedule,,,722.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,763.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,903.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,722.47,,,fee schedule,,,722.47,,,fee schedule,,,,,,,,,,,,,,,722.47,,,fee schedule,,,,,,,,,,,,,,,722.47,,,fee schedule,,,744.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,827.73,,,fee schedule,,,722.47,,,fee schedule,,,767.26,,,fee schedule,,,722.47,,,fee schedule,,,722.47,,,fee schedule,,,734.22,,,fee schedule,,,,,,,,,734.22,,,fee schedule,,,,,,,,
REMOVE TNL CV CATH,2800000076,CDM,761,RC,36589,CPT,76,EAPG,,,,outpatient,facility,,,1325.85,1325.85,768.15,1126.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.11,,,fee schedule,,,768.15,,,fee schedule,,,1001.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,768.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,768.15,,,fee schedule,,,768.15,,,fee schedule,,,768.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,768.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,768.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DRAW BLOOD OFF VENOUS DEVICE,2800000077,CDM,761,RC,36591,CPT,,,,,,inpatient,facility,,,388.42,388.42,31.07,388.42,,,,,,,,,,,,,,388.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.58,,,percent of total billed charges,,,,,,,,,388.42,,,percent of total billed charges,,,215.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.42,,,percent of total billed charges,,,,,,,,,,,,,,,388.42,,,percent of total billed charges,,,202.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.07,,,percent of total billed charges,,,388.42,,,percent of total billed charges,,,388.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,388.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.75,,,percent of total billed charges,,
DRAW BLOOD OFF VENOUS DEVICE,2800000077,CDM,761,RC,36591,CPT,,,,,,outpatient,facility,,,388.42,388.42,31.07,618.77,,226.84,,,percent of total billed charges,,,,,,,,,388.42,,,percent of total billed charges,,,173.77,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,193.37,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,193.37,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,388.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,349.58,,,percent of total billed charges,,,,,,,,,388.42,,,percent of total billed charges,,,263.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.31,,,percent of total billed charges,,,,,,,,,,,,,,,266.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",281.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,388.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,202.52,,,percent of total billed charges,,,388.42,,,percent of total billed charges,,,388.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,295.2,,,percent of total billed charges,,,147.13,,,percent of total billed charges,,,201.16,,,percent of total billed charges,,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,319.13,,,fee schedule,,,142.29,,,fee schedule,,,,,,,,,,,,,,,31.07,,,percent of total billed charges,,,388.42,,,percent of total billed charges,,,388.42,,,percent of total billed charges,,,,,,,,,,,,,,,388.42,,,percent of total billed charges,,,388.42,,,percent of total billed charges,,,,,,,,,153.08,,,fee schedule,,,313.67,,,fee schedule,,,,,,,,,,,,,,,275.84,,,fee schedule,,,367.78,,,fee schedule,,,203.89,,,fee schedule,,,291.31,,,percent of total billed charges,,,388.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,388.42,,,percent of total billed charges,,,388.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,272.75,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
DRAW BLOOD OFF VENOUS DEVICE,2800000077,CDM,761,RC,36591,CPT,5734,APC,,,,outpatient,facility,,,388.42,388.42,145.36,218.41,,,,,,,,155.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.14,,,fee schedule,,,,,,,,,150.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,150.63,,,fee schedule,,,,,,,,,,,,,,,158.13,,,fee schedule,,,158.16,,,fee schedule,,,,,,,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,158.16,,,fee schedule,,,,,,,,,,,,,,,218.41,,,fee schedule,,,,,,,,,,,,,,,155.13,,,fee schedule,,,,,,,,,,,,,,,145.36,,,fee schedule,,,161.17,,,fee schedule,,,160.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,159.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,188.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,,,,,,,,,,,,,150.63,,,fee schedule,,,,,,,,,,,,,,,150.63,,,fee schedule,,,155.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.31,,,fee schedule,,,150.63,,,fee schedule,,,159.97,,,fee schedule,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,153.08,,,fee schedule,,,,,,,,,153.08,,,fee schedule,,,,,,,,
DRAW BLOOD OFF VENOUS DEVICE,2800000077,CDM,761,RC,36591,CPT,999,EAPG,,,,outpatient,facility,,,388.42,388.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COLLECT BLOOD FROM PICC,2800000078,CDM,761,RC,36592,CPT,,,,,,inpatient,facility,,,275,275,22,275,,,,,,,,,,,,,,275,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,275,,,percent of total billed charges,,,152.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,275,,,percent of total billed charges,,,,,,,,,,,,,,,275,,,percent of total billed charges,,,143.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22,,,percent of total billed charges,,,275,,,percent of total billed charges,,,275,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,275,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.1,,,percent of total billed charges,,
COLLECT BLOOD FROM PICC,2800000078,CDM,761,RC,36592,CPT,,,,,,outpatient,facility,,,275,275,22,618.77,,160.6,,,percent of total billed charges,,,,,,,,,275,,,percent of total billed charges,,,173.77,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,193.37,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,193.37,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,275,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,247.5,,,percent of total billed charges,,,,,,,,,275,,,percent of total billed charges,,,186.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,,,,,,,,,,,266.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",281.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,275,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,143.38,,,percent of total billed charges,,,275,,,percent of total billed charges,,,275,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209,,,percent of total billed charges,,,104.17,,,percent of total billed charges,,,142.42,,,percent of total billed charges,,,,,,,,,,,,,,,55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,275,,,fee schedule,,,142.29,,,fee schedule,,,,,,,,,,,,,,,22,,,percent of total billed charges,,,275,,,percent of total billed charges,,,275,,,percent of total billed charges,,,,,,,,,,,,,,,275,,,percent of total billed charges,,,275,,,percent of total billed charges,,,,,,,,,153.08,,,fee schedule,,,275,,,fee schedule,,,,,,,,,,,,,,,275,,,fee schedule,,,275,,,fee schedule,,,203.89,,,fee schedule,,,206.25,,,percent of total billed charges,,,275,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,275,,,percent of total billed charges,,,275,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,193.1,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
COLLECT BLOOD FROM PICC,2800000078,CDM,761,RC,36592,CPT,5734,APC,,,,outpatient,facility,,,275,275,145.36,218.41,,,,,,,,155.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.14,,,fee schedule,,,,,,,,,150.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,150.63,,,fee schedule,,,,,,,,,,,,,,,158.13,,,fee schedule,,,158.16,,,fee schedule,,,,,,,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,158.16,,,fee schedule,,,,,,,,,,,,,,,218.41,,,fee schedule,,,,,,,,,,,,,,,155.13,,,fee schedule,,,,,,,,,,,,,,,145.36,,,fee schedule,,,161.17,,,fee schedule,,,160.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,159.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,188.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,,,,,,,,,,,,,150.63,,,fee schedule,,,,,,,,,,,,,,,150.63,,,fee schedule,,,155.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.31,,,fee schedule,,,150.63,,,fee schedule,,,159.97,,,fee schedule,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,153.08,,,fee schedule,,,,,,,,,153.08,,,fee schedule,,,,,,,,
COLLECT BLOOD FROM PICC,2800000078,CDM,761,RC,36592,CPT,999,EAPG,,,,outpatient,facility,,,275,275,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DECLOT VASCULAR DEVICE,2800000079,CDM,761,RC,36593,CPT,,,,,,inpatient,facility,,,893.1,893.1,71.45,893.1,,,,,,,,,,,,,,893.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,803.79,,,percent of total billed charges,,,,,,,,,893.1,,,percent of total billed charges,,,494.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,814.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,893.1,,,percent of total billed charges,,,,,,,,,,,,,,,893.1,,,percent of total billed charges,,,465.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.45,,,percent of total billed charges,,,893.1,,,percent of total billed charges,,,893.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,893.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,627.13,,,percent of total billed charges,,
DECLOT VASCULAR DEVICE,2800000079,CDM,761,RC,36593,CPT,,,,,,outpatient,facility,,,893.1,893.1,22.06,893.1,,521.57,,,percent of total billed charges,,,,,,,,,893.1,,,percent of total billed charges,,,470.6,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,523.69,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,523.69,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,893.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,803.79,,,percent of total billed charges,,,,,,,,,893.1,,,percent of total billed charges,,,604.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.9,,,percent of total billed charges,,,,,,,,,,,,,,,583.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",617.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,893.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,465.66,,,percent of total billed charges,,,893.1,,,percent of total billed charges,,,893.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,678.76,,,percent of total billed charges,,,338.31,,,percent of total billed charges,,,462.54,,,percent of total billed charges,,,,,,,,,,,,,,,178.62,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,893.1,,,fee schedule,,,407.17,,,fee schedule,,,,,,,,,,,,,,,71.45,,,percent of total billed charges,,,893.1,,,percent of total billed charges,,,893.1,,,percent of total billed charges,,,,,,,,,,,,,,,893.1,,,percent of total billed charges,,,893.1,,,percent of total billed charges,,,,,,,,,393.9,,,fee schedule,,,893.1,,,fee schedule,,,,,,,,,,,,,,,789.32,,,fee schedule,,,893.1,,,fee schedule,,,583.43,,,fee schedule,,,669.83,,,percent of total billed charges,,,893.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,893.1,,,percent of total billed charges,,,893.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,22.06,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
DECLOT VASCULAR DEVICE,2800000079,CDM,761,RC,36593,CPT,5694,APC,,,,outpatient,facility,,,893.1,893.1,374.03,562.02,,,,,,,,399.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,387.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.48,,,fee schedule,,,,,,,,,387.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,387.6,,,fee schedule,,,,,,,,,,,,,,,406.89,,,fee schedule,,,406.98,,,fee schedule,,,,,,,,,387.6,,,fee schedule,,,387.6,,,fee schedule,,,406.98,,,fee schedule,,,,,,,,,,,,,,,562.02,,,fee schedule,,,,,,,,,,,,,,,399.18,,,fee schedule,,,,,,,,,,,,,,,374.03,,,fee schedule,,,414.73,,,fee schedule,,,413.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,387.6,,,fee schedule,,,387.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,409.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,484.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,484.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,387.6,,,fee schedule,,,387.6,,,fee schedule,,,,,,,,,,,,,,,387.6,,,fee schedule,,,,,,,,,,,,,,,387.6,,,fee schedule,,,399.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.23,,,fee schedule,,,387.6,,,fee schedule,,,411.63,,,fee schedule,,,387.6,,,fee schedule,,,387.6,,,fee schedule,,,393.9,,,fee schedule,,,,,,,,,393.9,,,fee schedule,,,,,,,,
DECLOT VASCULAR DEVICE,2800000079,CDM,761,RC,36593,CPT,111,EAPG,,,,outpatient,facility,,,893.1,893.1,248.41,364.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.17,,,fee schedule,,,248.41,,,fee schedule,,,323.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,248.41,,,fee schedule,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIMP BLADR IRRIG LAVGE/INSTILL,2800000085,CDM,761,RC,51700,CPT,,,,,,inpatient,facility,,,728.88,728.88,58.31,728.88,,,,,,,,,,,,,,728.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.99,,,percent of total billed charges,,,,,,,,,728.88,,,percent of total billed charges,,,403.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,665.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728.88,,,percent of total billed charges,,,,,,,,,,,,,,,728.88,,,percent of total billed charges,,,380.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.31,,,percent of total billed charges,,,728.88,,,percent of total billed charges,,,728.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,728.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.82,,,percent of total billed charges,,
SIMP BLADR IRRIG LAVGE/INSTILL,2800000085,CDM,761,RC,51700,CPT,,,,,,outpatient,facility,,,728.88,728.88,57,728.88,,425.67,,,percent of total billed charges,,,,,,,,,728.88,,,percent of total billed charges,,,377.64,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,420.25,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,420.25,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,728.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,655.99,,,percent of total billed charges,,,,,,,,,728.88,,,percent of total billed charges,,,493.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,559.78,,,percent of total billed charges,,,,,,,,,,,,,,,603.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",638.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,728.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,380.04,,,percent of total billed charges,,,728.88,,,percent of total billed charges,,,728.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,553.95,,,percent of total billed charges,,,276.1,,,percent of total billed charges,,,377.49,,,percent of total billed charges,,,,,,,,,,,,,,,145.78,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,666.12,,,fee schedule,,,296.99,,,fee schedule,,,,,,,,,,,,,,,58.31,,,percent of total billed charges,,,728.88,,,percent of total billed charges,,,728.88,,,percent of total billed charges,,,,,,,,,,,,,,,728.88,,,percent of total billed charges,,,728.88,,,percent of total billed charges,,,,,,,,,288.83,,,fee schedule,,,654.71,,,fee schedule,,,,,,,,,,,,,,,575.74,,,fee schedule,,,728.88,,,fee schedule,,,425.56,,,fee schedule,,,546.66,,,percent of total billed charges,,,728.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,728.88,,,percent of total billed charges,,,728.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,57,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
SIMP BLADR IRRIG LAVGE/INSTILL,2800000085,CDM,761,RC,51700,CPT,5371,APC,,,,outpatient,facility,,,728.88,728.88,274.26,412.1,,,,,,,,292.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,284.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.05,,,fee schedule,,,,,,,,,284.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,284.21,,,fee schedule,,,,,,,,,,,,,,,298.36,,,fee schedule,,,298.42,,,fee schedule,,,,,,,,,284.21,,,fee schedule,,,284.21,,,fee schedule,,,298.42,,,fee schedule,,,,,,,,,,,,,,,412.1,,,fee schedule,,,,,,,,,,,,,,,292.7,,,fee schedule,,,,,,,,,,,,,,,274.26,,,fee schedule,,,304.1,,,fee schedule,,,303.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284.21,,,fee schedule,,,284.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,300.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,355.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,284.21,,,fee schedule,,,284.21,,,fee schedule,,,,,,,,,,,,,,,284.21,,,fee schedule,,,,,,,,,,,,,,,284.21,,,fee schedule,,,292.74,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.64,,,fee schedule,,,284.21,,,fee schedule,,,301.83,,,fee schedule,,,284.21,,,fee schedule,,,284.21,,,fee schedule,,,288.83,,,fee schedule,,,,,,,,,288.83,,,fee schedule,,,,,,,,
SIMP BLADR IRRIG LAVGE/INSTILL,2800000085,CDM,761,RC,51700,CPT,159,EAPG,,,,outpatient,facility,,,728.88,728.88,113.28,166.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.07,,,fee schedule,,,113.28,,,fee schedule,,,147.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.28,,,fee schedule,,,113.28,,,fee schedule,,,113.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,113.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT BLADDER CATHETER,2800000086,CDM,761,RC,51701,CPT,,,,,,inpatient,facility,,,320.59,320.59,25.65,320.59,,,,,,,,,,,,,,320.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288.53,,,percent of total billed charges,,,,,,,,,320.59,,,percent of total billed charges,,,177.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,292.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.59,,,percent of total billed charges,,,,,,,,,,,,,,,320.59,,,percent of total billed charges,,,167.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.65,,,percent of total billed charges,,,320.59,,,percent of total billed charges,,,320.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,320.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,225.12,,,percent of total billed charges,,
INSERT BLADDER CATHETER,2800000086,CDM,761,RC,51701,CPT,,,,,,outpatient,facility,,,320.59,320.59,25.65,618.77,,187.22,,,percent of total billed charges,,,,,,,,,320.59,,,percent of total billed charges,,,173.77,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,193.37,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,193.37,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,320.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,288.53,,,percent of total billed charges,,,,,,,,,320.59,,,percent of total billed charges,,,217.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.21,,,percent of total billed charges,,,,,,,,,,,,,,,266.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",281.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,320.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,167.16,,,percent of total billed charges,,,320.59,,,percent of total billed charges,,,320.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.65,,,percent of total billed charges,,,121.44,,,percent of total billed charges,,,166.03,,,percent of total billed charges,,,,,,,,,,,,,,,64.12,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,319.13,,,fee schedule,,,142.29,,,fee schedule,,,,,,,,,,,,,,,25.65,,,percent of total billed charges,,,320.59,,,percent of total billed charges,,,320.59,,,percent of total billed charges,,,,,,,,,,,,,,,320.59,,,percent of total billed charges,,,320.59,,,percent of total billed charges,,,,,,,,,153.08,,,fee schedule,,,313.67,,,fee schedule,,,,,,,,,,,,,,,275.84,,,fee schedule,,,320.59,,,fee schedule,,,203.89,,,fee schedule,,,240.44,,,percent of total billed charges,,,320.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,320.59,,,percent of total billed charges,,,320.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,28.19,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
INSERT BLADDER CATHETER,2800000086,CDM,761,RC,51701,CPT,5734,APC,,,,outpatient,facility,,,320.59,320.59,145.36,218.41,,,,,,,,155.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.14,,,fee schedule,,,,,,,,,150.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,150.63,,,fee schedule,,,,,,,,,,,,,,,158.13,,,fee schedule,,,158.16,,,fee schedule,,,,,,,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,158.16,,,fee schedule,,,,,,,,,,,,,,,218.41,,,fee schedule,,,,,,,,,,,,,,,155.13,,,fee schedule,,,,,,,,,,,,,,,145.36,,,fee schedule,,,161.17,,,fee schedule,,,160.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,159.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,188.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,,,,,,,,,,,,,150.63,,,fee schedule,,,,,,,,,,,,,,,150.63,,,fee schedule,,,155.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.31,,,fee schedule,,,150.63,,,fee schedule,,,159.97,,,fee schedule,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,153.08,,,fee schedule,,,,,,,,,153.08,,,fee schedule,,,,,,,,
INSERT BLADDER CATHETER,2800000086,CDM,761,RC,51701,CPT,999,EAPG,,,,outpatient,facility,,,320.59,320.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INS TEMP BLADDER CATH,2800000087,CDM,761,RC,51702,CPT,,,,,,inpatient,facility,,,341.43,341.43,27.31,341.43,,,,,,,,,,,,,,341.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.29,,,percent of total billed charges,,,,,,,,,341.43,,,percent of total billed charges,,,189.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,311.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.43,,,percent of total billed charges,,,,,,,,,,,,,,,341.43,,,percent of total billed charges,,,178.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.31,,,percent of total billed charges,,,341.43,,,percent of total billed charges,,,341.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,341.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.75,,,percent of total billed charges,,
INS TEMP BLADDER CATH,2800000087,CDM,761,RC,51702,CPT,,,,,,outpatient,facility,,,341.43,341.43,27.31,618.77,,199.4,,,percent of total billed charges,,,,,,,,,341.43,,,percent of total billed charges,,,173.77,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,193.37,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,193.37,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,341.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,307.29,,,percent of total billed charges,,,,,,,,,341.43,,,percent of total billed charges,,,231.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.22,,,percent of total billed charges,,,,,,,,,,,,,,,266.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",281.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,341.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.02,,,percent of total billed charges,,,341.43,,,percent of total billed charges,,,341.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.49,,,percent of total billed charges,,,129.33,,,percent of total billed charges,,,176.83,,,percent of total billed charges,,,,,,,,,,,,,,,68.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,319.13,,,fee schedule,,,142.29,,,fee schedule,,,,,,,,,,,,,,,27.31,,,percent of total billed charges,,,341.43,,,percent of total billed charges,,,341.43,,,percent of total billed charges,,,,,,,,,,,,,,,341.43,,,percent of total billed charges,,,341.43,,,percent of total billed charges,,,,,,,,,153.08,,,fee schedule,,,313.67,,,fee schedule,,,,,,,,,,,,,,,275.84,,,fee schedule,,,341.43,,,fee schedule,,,203.89,,,fee schedule,,,256.07,,,percent of total billed charges,,,341.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,341.43,,,percent of total billed charges,,,341.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,28.19,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
INS TEMP BLADDER CATH,2800000087,CDM,761,RC,51702,CPT,5734,APC,,,,outpatient,facility,,,341.43,341.43,145.36,218.41,,,,,,,,155.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.14,,,fee schedule,,,,,,,,,150.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,150.63,,,fee schedule,,,,,,,,,,,,,,,158.13,,,fee schedule,,,158.16,,,fee schedule,,,,,,,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,158.16,,,fee schedule,,,,,,,,,,,,,,,218.41,,,fee schedule,,,,,,,,,,,,,,,155.13,,,fee schedule,,,,,,,,,,,,,,,145.36,,,fee schedule,,,161.17,,,fee schedule,,,160.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,159.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,188.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,,,,,,,,,,,,,150.63,,,fee schedule,,,,,,,,,,,,,,,150.63,,,fee schedule,,,155.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.31,,,fee schedule,,,150.63,,,fee schedule,,,159.97,,,fee schedule,,,150.63,,,fee schedule,,,150.63,,,fee schedule,,,153.08,,,fee schedule,,,,,,,,,153.08,,,fee schedule,,,,,,,,
INS TEMP BLADDER CATH,2800000087,CDM,761,RC,51702,CPT,999,EAPG,,,,outpatient,facility,,,341.43,341.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHANGE OF CYSTOSTOMY TUBE SMPL,2800000088,CDM,761,RC,51705,CPT,,,,,,inpatient,facility,,,1212.03,1212.03,96.96,1212.03,,,,,,,,,,,,,,1212.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1090.83,,,percent of total billed charges,,,,,,,,,1212.03,,,percent of total billed charges,,,670.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1212.03,,,percent of total billed charges,,,,,,,,,,,,,,,1212.03,,,percent of total billed charges,,,631.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.96,,,percent of total billed charges,,,1212.03,,,percent of total billed charges,,,1212.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1212.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,851.09,,,percent of total billed charges,,
CHANGE OF CYSTOSTOMY TUBE SMPL,2800000088,CDM,761,RC,51705,CPT,,,,,,outpatient,facility,,,1212.03,1212.03,79.07,1212.03,,707.83,,,percent of total billed charges,,,,,,,,,1212.03,,,percent of total billed charges,,,377.64,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,420.25,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,420.25,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1212.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1090.83,,,percent of total billed charges,,,,,,,,,1212.03,,,percent of total billed charges,,,820.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.84,,,percent of total billed charges,,,,,,,,,,,,,,,603.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",638.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1212.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,631.95,,,percent of total billed charges,,,1212.03,,,percent of total billed charges,,,1212.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,921.14,,,percent of total billed charges,,,459.12,,,percent of total billed charges,,,627.71,,,percent of total billed charges,,,,,,,,,,,,,,,242.41,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,666.12,,,fee schedule,,,296.99,,,fee schedule,,,,,,,,,,,,,,,96.96,,,percent of total billed charges,,,1212.03,,,percent of total billed charges,,,1212.03,,,percent of total billed charges,,,,,,,,,,,,,,,1212.03,,,percent of total billed charges,,,1212.03,,,percent of total billed charges,,,,,,,,,288.83,,,fee schedule,,,654.71,,,fee schedule,,,,,,,,,,,,,,,575.74,,,fee schedule,,,767.65,,,fee schedule,,,425.56,,,fee schedule,,,909.02,,,percent of total billed charges,,,1212.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1212.03,,,percent of total billed charges,,,1212.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,606.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,79.07,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
CHANGE OF CYSTOSTOMY TUBE SMPL,2800000088,CDM,761,RC,51705,CPT,5371,APC,,,,outpatient,facility,,,1212.03,1212.03,274.26,412.1,,,,,,,,292.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,284.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.05,,,fee schedule,,,,,,,,,284.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,284.21,,,fee schedule,,,,,,,,,,,,,,,298.36,,,fee schedule,,,298.42,,,fee schedule,,,,,,,,,284.21,,,fee schedule,,,284.21,,,fee schedule,,,298.42,,,fee schedule,,,,,,,,,,,,,,,412.1,,,fee schedule,,,,,,,,,,,,,,,292.7,,,fee schedule,,,,,,,,,,,,,,,274.26,,,fee schedule,,,304.1,,,fee schedule,,,303.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284.21,,,fee schedule,,,284.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,300.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,355.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,284.21,,,fee schedule,,,284.21,,,fee schedule,,,,,,,,,,,,,,,284.21,,,fee schedule,,,,,,,,,,,,,,,284.21,,,fee schedule,,,292.74,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.64,,,fee schedule,,,284.21,,,fee schedule,,,301.83,,,fee schedule,,,284.21,,,fee schedule,,,284.21,,,fee schedule,,,288.83,,,fee schedule,,,,,,,,,288.83,,,fee schedule,,,,,,,,
CHANGE OF CYSTOSTOMY TUBE SMPL,2800000088,CDM,761,RC,51705,CPT,159,EAPG,,,,outpatient,facility,,,1212.03,1212.03,113.28,166.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.07,,,fee schedule,,,113.28,,,fee schedule,,,147.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.28,,,fee schedule,,,113.28,,,fee schedule,,,113.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,113.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TREATMENT OF BLADDER LESION,2800000089,CDM,761,RC,51720,CPT,,,,,,inpatient,facility,,,1154.31,1154.31,92.34,1154.31,,,,,,,,,,,,,,1154.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1038.88,,,percent of total billed charges,,,,,,,,,1154.31,,,percent of total billed charges,,,639.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1053.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1154.31,,,percent of total billed charges,,,,,,,,,,,,,,,1154.31,,,percent of total billed charges,,,601.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.34,,,percent of total billed charges,,,1154.31,,,percent of total billed charges,,,1154.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1154.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,810.56,,,percent of total billed charges,,
TREATMENT OF BLADDER LESION,2800000089,CDM,761,RC,51720,CPT,,,,,,outpatient,facility,,,1154.31,1154.31,61.77,1154.31,,674.12,,,percent of total billed charges,,,,,,,,,1154.31,,,percent of total billed charges,,,377.64,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,420.25,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,420.25,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1154.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1038.88,,,percent of total billed charges,,,,,,,,,1154.31,,,percent of total billed charges,,,781.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,886.51,,,percent of total billed charges,,,,,,,,,,,,,,,603.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",638.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1154.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,601.86,,,percent of total billed charges,,,1154.31,,,percent of total billed charges,,,1154.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,877.28,,,percent of total billed charges,,,437.25,,,percent of total billed charges,,,597.82,,,percent of total billed charges,,,,,,,,,,,,,,,230.86,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,999.26,,,fee schedule,,,445.53,,,fee schedule,,,,,,,,,,,,,,,92.34,,,percent of total billed charges,,,1154.31,,,percent of total billed charges,,,1154.31,,,percent of total billed charges,,,,,,,,,,,,,,,1154.31,,,percent of total billed charges,,,1154.31,,,percent of total billed charges,,,,,,,,,792.66,,,fee schedule,,,982.15,,,fee schedule,,,,,,,,,,,,,,,863.69,,,fee schedule,,,1151.58,,,fee schedule,,,638.4,,,fee schedule,,,865.73,,,percent of total billed charges,,,1154.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1154.31,,,percent of total billed charges,,,1154.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,61.77,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
TREATMENT OF BLADDER LESION,2800000089,CDM,761,RC,51720,CPT,5372,APC,,,,outpatient,facility,,,1154.31,1154.31,752.68,1130.97,,,,,,,,803.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,779.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.78,,,fee schedule,,,,,,,,,779.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,779.98,,,fee schedule,,,,,,,,,,,,,,,818.81,,,fee schedule,,,818.98,,,fee schedule,,,,,,,,,779.98,,,fee schedule,,,779.98,,,fee schedule,,,818.98,,,fee schedule,,,,,,,,,,,,,,,1130.97,,,fee schedule,,,,,,,,,,,,,,,803.28,,,fee schedule,,,,,,,,,,,,,,,752.68,,,fee schedule,,,834.58,,,fee schedule,,,832.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,779.98,,,fee schedule,,,779.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,824.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,974.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,974.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,779.98,,,fee schedule,,,779.98,,,fee schedule,,,,,,,,,,,,,,,779.98,,,fee schedule,,,,,,,,,,,,,,,779.98,,,fee schedule,,,803.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,900.06,,,fee schedule,,,779.98,,,fee schedule,,,828.33,,,fee schedule,,,779.98,,,fee schedule,,,779.98,,,fee schedule,,,792.66,,,fee schedule,,,,,,,,,792.66,,,fee schedule,,,,,,,,
TREATMENT OF BLADDER LESION,2800000089,CDM,761,RC,51720,CPT,161,EAPG,,,,outpatient,facility,,,1154.31,1154.31,942.93,1382.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1382.34,,,fee schedule,,,942.93,,,fee schedule,,,1228.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,942.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,942.93,,,fee schedule,,,942.93,,,fee schedule,,,942.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,942.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,942.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
US PV RESIDUAL URINE,2800000090,CDM,761,RC,51798,CPT,,,,,,inpatient,facility,,,223.7,223.7,17.9,223.7,,,,,,,,,,,,,,223.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.33,,,percent of total billed charges,,,,,,,,,223.7,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,204.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.7,,,percent of total billed charges,,,,,,,,,,,,,,,223.7,,,percent of total billed charges,,,116.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.9,,,percent of total billed charges,,,223.7,,,percent of total billed charges,,,223.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,223.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.08,,,percent of total billed charges,,
US PV RESIDUAL URINE,2800000090,CDM,761,RC,51798,CPT,,,,,,outpatient,facility,,,223.7,223.7,17.28,618.77,,130.64,,,percent of total billed charges,,,,,,,,,223.7,,,percent of total billed charges,,,91.21,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,101.5,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,101.5,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,223.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,201.33,,,percent of total billed charges,,,,,,,,,223.7,,,percent of total billed charges,,,151.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.8,,,percent of total billed charges,,,,,,,,,,,,,,,266.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",281.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,223.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,116.64,,,percent of total billed charges,,,223.7,,,percent of total billed charges,,,223.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.01,,,percent of total billed charges,,,84.74,,,percent of total billed charges,,,115.85,,,percent of total billed charges,,,,,,,,,,,,,,,44.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,157.8,,,fee schedule,,,70.36,,,fee schedule,,,,,,,,,,,,,,,17.9,,,percent of total billed charges,,,223.7,,,percent of total billed charges,,,223.7,,,percent of total billed charges,,,,,,,,,,,,,,,223.7,,,percent of total billed charges,,,223.7,,,percent of total billed charges,,,,,,,,,70.54,,,fee schedule,,,155.1,,,fee schedule,,,,,,,,,,,,,,,136.39,,,fee schedule,,,181.85,,,fee schedule,,,100.82,,,fee schedule,,,167.77,,,percent of total billed charges,,,223.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,223.7,,,percent of total billed charges,,,223.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.28,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
US PV RESIDUAL URINE,2800000090,CDM,761,RC,51798,CPT,5733,APC,,,,outpatient,facility,,,223.7,223.7,66.98,100.64,,,,,,,,71.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,69.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.1,,,fee schedule,,,,,,,,,69.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,69.41,,,fee schedule,,,,,,,,,,,,,,,72.87,,,fee schedule,,,72.88,,,fee schedule,,,,,,,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,72.88,,,fee schedule,,,,,,,,,,,,,,,100.64,,,fee schedule,,,,,,,,,,,,,,,71.49,,,fee schedule,,,,,,,,,,,,,,,66.98,,,fee schedule,,,74.27,,,fee schedule,,,74.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,73.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,86.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,,,,,,,,,,,,,69.41,,,fee schedule,,,,,,,,,,,,,,,69.41,,,fee schedule,,,71.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.59,,,fee schedule,,,69.41,,,fee schedule,,,73.71,,,fee schedule,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,70.54,,,fee schedule,,,,,,,,,70.54,,,fee schedule,,,,,,,,
US PV RESIDUAL URINE,2800000090,CDM,761,RC,51798,CPT,159,EAPG,,,,outpatient,facility,,,223.7,223.7,113.28,166.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.07,,,fee schedule,,,113.28,,,fee schedule,,,147.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.28,,,fee schedule,,,113.28,,,fee schedule,,,113.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,113.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CYSTOURETHROSCOPY,2800000091,CDM,761,RC,52000,CPT,,,,,,inpatient,facility,,,1807.08,1807.08,144.57,1807.08,,,,,,,,,,,,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.37,,,percent of total billed charges,,,,,,,,,1807.08,,,percent of total billed charges,,,1000.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1648.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,1807.08,,,percent of total billed charges,,,942.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,361.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.57,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1268.93,,,percent of total billed charges,,
CYSTOURETHROSCOPY,2800000091,CDM,761,RC,52000,CPT,,,,,,outpatient,facility,,,1807.08,1807.08,144.57,1857.83,,1055.33,,,percent of total billed charges,,,,,,,,,1807.08,,,percent of total billed charges,,,917.5,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1021.02,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1021.02,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1626.37,,,percent of total billed charges,,,,,,,,,1807.08,,,percent of total billed charges,,,1223.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1387.84,,,percent of total billed charges,,,,,,,,,,,,,,,1531.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",1620.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,942.21,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,,,case rate,,,684.52,,,percent of total billed charges,,,935.89,,,percent of total billed charges,,,,,,,,,,,,,,,361.42,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,144.57,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,1807.08,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,,,,,,,792.66,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1355.31,,,percent of total billed charges,,,1807.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1807.08,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,266.95,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
CYSTOURETHROSCOPY,2800000091,CDM,761,RC,52000,CPT,5372,APC,,,,outpatient,facility,,,1807.08,1807.08,752.68,1130.97,,,,,,,,803.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,779.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.78,,,fee schedule,,,,,,,,,779.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,779.98,,,fee schedule,,,,,,,,,,,,,,,818.81,,,fee schedule,,,818.98,,,fee schedule,,,,,,,,,779.98,,,fee schedule,,,779.98,,,fee schedule,,,818.98,,,fee schedule,,,,,,,,,,,,,,,1130.97,,,fee schedule,,,,,,,,,,,,,,,803.28,,,fee schedule,,,,,,,,,,,,,,,752.68,,,fee schedule,,,834.58,,,fee schedule,,,832.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,779.98,,,fee schedule,,,779.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,824.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,974.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,974.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,779.98,,,fee schedule,,,779.98,,,fee schedule,,,,,,,,,,,,,,,779.98,,,fee schedule,,,,,,,,,,,,,,,779.98,,,fee schedule,,,803.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,900.06,,,fee schedule,,,779.98,,,fee schedule,,,828.33,,,fee schedule,,,779.98,,,fee schedule,,,779.98,,,fee schedule,,,792.66,,,fee schedule,,,,,,,,,792.66,,,fee schedule,,,,,,,,
CYSTOURETHROSCOPY,2800000091,CDM,761,RC,52000,CPT,173,EAPG,,,,outpatient,facility,,,1807.08,1807.08,1556.92,2282.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2282.44,,,fee schedule,,,1556.92,,,fee schedule,,,2029.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1556.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1556.92,,,fee schedule,,,1556.92,,,fee schedule,,,1556.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1556.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1556.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CYSTO W REM FB/STNT URTH/BLDR,2800000092,CDM,761,RC,52310,CPT,,,,,,inpatient,facility,,,4367.96,4367.96,349.44,4367.96,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3931.16,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2418.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3985.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,2277.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.44,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3067.18,,,percent of total billed charges,,
CYSTO W REM FB/STNT URTH/BLDR,2800000092,CDM,761,RC,52310,CPT,,,,,,outpatient,facility,,,4367.96,4367.96,319.69,4654.84,,2550.89,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2839.02,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,3159.33,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,3159.33,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3931.16,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2957.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3354.59,,,percent of total billed charges,,,,,,,,,,,,,,,4398.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",4654.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2277.45,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1250,,,case rate,,,1654.58,,,percent of total billed charges,,,2262.17,,,percent of total billed charges,,,,,,,,,,,,,,,873.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3873.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",1726.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,349.44,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,2432.73,,,fee schedule,,,4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,3321.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",2878.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",3275.97,,,percent of total billed charges,,,4367.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2183.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,801.8,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
CYSTO W REM FB/STNT URTH/BLDR,2800000092,CDM,761,RC,52310,CPT,5373,APC,,,,outpatient,facility,,,4367.96,4367.96,2310.03,3471.02,,,,,,,,2465.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,2393.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2417.75,,,fee schedule,,,,,,,,,2393.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,2393.81,,,fee schedule,,,,,,,,,,,,,,,2513.01,,,fee schedule,,,2513.5,,,fee schedule,,,,,,,,,2393.81,,,fee schedule,,,2393.81,,,fee schedule,,,2513.5,,,fee schedule,,,,,,,,,,,,,,,3471.02,,,fee schedule,,,,,,,,,,,,,,,2465.33,,,fee schedule,,,,,,,,,,,,,,,2310.03,,,fee schedule,,,2561.38,,,fee schedule,,,2554.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2393.81,,,fee schedule,,,2393.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2530.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2992.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2992.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,2393.81,,,fee schedule,,,2393.81,,,fee schedule,,,,,,,,,,,,,,,2393.81,,,fee schedule,,,,,,,,,,,,,,,2393.81,,,fee schedule,,,2465.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2683.72,,,fee schedule,,,2393.81,,,fee schedule,,,2542.2,,,fee schedule,,,2393.81,,,fee schedule,,,2393.81,,,fee schedule,,,2432.73,,,fee schedule,,,,,,,,,2432.73,,,fee schedule,,,,,,,,
CYSTO W REM FB/STNT URTH/BLDR,2800000092,CDM,761,RC,52310,CPT,173,EAPG,,,,outpatient,facility,,,4367.96,4367.96,1556.92,2282.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2282.44,,,fee schedule,,,1556.92,,,fee schedule,,,2029.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1556.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1556.92,,,fee schedule,,,1556.92,,,fee schedule,,,1556.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1556.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1556.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
I&D OF VULVA/PERINEAL ABSCESS,2800000093,CDM,761,RC,56405,CPT,,,,,,inpatient,facility,,,1897.43,1897.43,151.79,1897.43,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1707.69,,,percent of total billed charges,,,,,,,,,1897.43,,,percent of total billed charges,,,1050.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1731.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,989.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,379.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.79,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1332.38,,,percent of total billed charges,,
I&D OF VULVA/PERINEAL ABSCESS,2800000093,CDM,761,RC,56405,CPT,,,,,,outpatient,facility,,,1897.43,1897.43,45.97,1897.43,,1108.1,,,percent of total billed charges,,,,,,,,,1897.43,,,percent of total billed charges,,,445.5,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,495.76,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,495.76,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1707.69,,,percent of total billed charges,,,,,,,,,1897.43,,,percent of total billed charges,,,1284.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1457.23,,,percent of total billed charges,,,,,,,,,,,,,,,732.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",775.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,989.32,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1442.05,,,percent of total billed charges,,,718.75,,,percent of total billed charges,,,982.68,,,percent of total billed charges,,,,,,,,,,,,,,,379.49,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,151.79,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,1897.43,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,,,,,,,361.24,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1423.07,,,percent of total billed charges,,,1897.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1897.43,,,percent of total billed charges,,,1897.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,45.97,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
I&D OF VULVA/PERINEAL ABSCESS,2800000093,CDM,761,RC,56405,CPT,5412,APC,,,,outpatient,facility,,,1897.43,1897.43,343.02,515.42,,,,,,,,366.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,355.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.01,,,fee schedule,,,,,,,,,355.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,355.46,,,fee schedule,,,,,,,,,,,,,,,373.16,,,fee schedule,,,373.23,,,fee schedule,,,,,,,,,355.46,,,fee schedule,,,355.46,,,fee schedule,,,373.23,,,fee schedule,,,,,,,,,,,,,,,515.42,,,fee schedule,,,,,,,,,,,,,,,366.08,,,fee schedule,,,,,,,,,,,,,,,343.02,,,fee schedule,,,380.34,,,fee schedule,,,379.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.46,,,fee schedule,,,355.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,375.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,444.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,444.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,355.46,,,fee schedule,,,355.46,,,fee schedule,,,,,,,,,,,,,,,355.46,,,fee schedule,,,,,,,,,,,,,,,355.46,,,fee schedule,,,366.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.7,,,fee schedule,,,355.46,,,fee schedule,,,377.5,,,fee schedule,,,355.46,,,fee schedule,,,355.46,,,fee schedule,,,361.24,,,fee schedule,,,,,,,,,361.24,,,fee schedule,,,,,,,,
I&D OF VULVA/PERINEAL ABSCESS,2800000093,CDM,761,RC,56405,CPT,417,EAPG,,,,outpatient,facility,,,1897.43,1897.43,187.77,275.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,275.27,,,fee schedule,,,187.77,,,fee schedule,,,244.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.77,,,fee schedule,,,187.77,,,fee schedule,,,187.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC NEUROFIBROM CUTANEOUS NRV,2800000097,CDM,761,RC,64788,CPT,,,,,,inpatient,facility,,,6409.39,6409.39,512.75,6409.39,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5768.45,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,3548.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5847.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,3341.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1281.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.75,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4500.67,,,percent of total billed charges,,
EXC NEUROFIBROM CUTANEOUS NRV,2800000097,CDM,761,RC,64788,CPT,,,,,,outpatient,facility,,,6409.39,6409.39,319.69,6930.49,,3743.08,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,2662.34,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2962.72,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2962.72,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5768.45,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,4340.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4922.41,,,percent of total billed charges,,,,,,,,,,,,,,,4066.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",4303.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3341.86,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1600,,,case rate,,,2427.88,,,percent of total billed charges,,,3319.42,,,percent of total billed charges,,,,,,,,,,,,,,,1281.88,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6061.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",2702.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,512.75,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,2319.03,,,fee schedule,,,6930.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,5197.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",6930.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",4504.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",4807.04,,,percent of total billed charges,,,6409.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,806.7,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC NEUROFIBROM CUTANEOUS NRV,2800000097,CDM,761,RC,64788,CPT,5431,APC,,,,outpatient,facility,,,6409.39,6409.39,2202.06,3308.8,,,,,,,,2350.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,2281.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2304.75,,,fee schedule,,,,,,,,,2281.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,2281.93,,,fee schedule,,,,,,,,,,,,,,,2395.56,,,fee schedule,,,2396.03,,,fee schedule,,,,,,,,,2281.93,,,fee schedule,,,2281.93,,,fee schedule,,,2396.03,,,fee schedule,,,,,,,,,,,,,,,3308.8,,,fee schedule,,,,,,,,,,,,,,,2350.1,,,fee schedule,,,,,,,,,,,,,,,2202.06,,,fee schedule,,,2441.67,,,fee schedule,,,2434.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2281.93,,,fee schedule,,,2281.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2411.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2852.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2852.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,2281.93,,,fee schedule,,,2281.93,,,fee schedule,,,,,,,,,,,,,,,2281.93,,,fee schedule,,,,,,,,,,,,,,,2281.93,,,fee schedule,,,2350.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2544.01,,,fee schedule,,,2281.93,,,fee schedule,,,2423.39,,,fee schedule,,,2281.93,,,fee schedule,,,2281.93,,,fee schedule,,,2319.03,,,fee schedule,,,,,,,,,2319.03,,,fee schedule,,,,,,,,
EXC NEUROFIBROM CUTANEOUS NRV,2800000097,CDM,761,RC,64788,CPT,217,EAPG,,,,outpatient,facility,,,6409.39,6409.39,1243.61,1823.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1823.13,,,fee schedule,,,1243.61,,,fee schedule,,,1620.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1243.61,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1243.61,,,fee schedule,,,1243.61,,,fee schedule,,,1243.61,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1243.61,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1243.61,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BX EXTERNAL EAR,2800000099,CDM,761,RC,69100,CPT,,,,,,inpatient,facility,,,1108.7,1108.7,88.7,1108.7,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,613.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1011.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,578.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,778.53,,,percent of total billed charges,,
BX EXTERNAL EAR,2800000099,CDM,761,RC,69100,CPT,,,,,,outpatient,facility,,,1108.7,1108.7,65.45,1185.37,,647.48,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,336.39,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,374.34,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,374.34,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,997.83,,,percent of total billed charges,,,,,,,,,1108.7,,,percent of total billed charges,,,750.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,851.48,,,percent of total billed charges,,,,,,,,,,,,,,,913.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",966.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,578.08,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,842.61,,,percent of total billed charges,,,419.98,,,percent of total billed charges,,,574.2,,,percent of total billed charges,,,,,,,,,,,,,,,221.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,88.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,275.78,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",831.53,,,percent of total billed charges,,,1108.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1108.7,,,percent of total billed charges,,,1108.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,554.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,65.45,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
BX EXTERNAL EAR,2800000099,CDM,761,RC,69100,CPT,5161,APC,,,,outpatient,facility,,,1108.7,1108.7,261.87,393.49,,,,,,,,279.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,271.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.08,,,fee schedule,,,,,,,,,271.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,271.37,,,fee schedule,,,,,,,,,,,,,,,284.88,,,fee schedule,,,284.94,,,fee schedule,,,,,,,,,271.37,,,fee schedule,,,271.37,,,fee schedule,,,284.94,,,fee schedule,,,,,,,,,,,,,,,393.49,,,fee schedule,,,,,,,,,,,,,,,279.47,,,fee schedule,,,,,,,,,,,,,,,261.87,,,fee schedule,,,290.37,,,fee schedule,,,289.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,271.37,,,fee schedule,,,271.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,286.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,339.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,271.37,,,fee schedule,,,271.37,,,fee schedule,,,,,,,,,,,,,,,271.37,,,fee schedule,,,,,,,,,,,,,,,271.37,,,fee schedule,,,279.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,321.85,,,fee schedule,,,271.37,,,fee schedule,,,288.19,,,fee schedule,,,271.37,,,fee schedule,,,271.37,,,fee schedule,,,275.78,,,fee schedule,,,,,,,,,275.78,,,fee schedule,,,,,,,,
BX EXTERNAL EAR,2800000099,CDM,761,RC,69100,CPT,249,EAPG,,,,outpatient,facility,,,1108.7,1108.7,194.73,285.47,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,285.47,,,fee schedule,,,194.73,,,fee schedule,,,253.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.73,,,fee schedule,,,194.73,,,fee schedule,,,194.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,194.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REMOVE IMPACTED EAR WAX UNI,2800000100,CDM,761,RC,69210,CPT,,,,,,inpatient,facility,,,283.66,283.66,22.69,283.66,,,,,,,,,,,,,,283.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.29,,,percent of total billed charges,,,,,,,,,283.66,,,percent of total billed charges,,,157.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.66,,,percent of total billed charges,,,,,,,,,,,,,,,283.66,,,percent of total billed charges,,,147.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.69,,,percent of total billed charges,,,283.66,,,percent of total billed charges,,,283.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,283.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.19,,,percent of total billed charges,,
REMOVE IMPACTED EAR WAX UNI,2800000100,CDM,761,RC,69210,CPT,,,,,,outpatient,facility,,,283.66,283.66,22.06,618.77,,165.66,,,percent of total billed charges,,,,,,,,,283.66,,,percent of total billed charges,,,91.21,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,101.5,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,101.5,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,283.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,255.29,,,percent of total billed charges,,,,,,,,,283.66,,,percent of total billed charges,,,192.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.85,,,percent of total billed charges,,,,,,,,,,,,,,,163.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",172.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,283.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,147.9,,,percent of total billed charges,,,283.66,,,percent of total billed charges,,,283.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.58,,,percent of total billed charges,,,107.45,,,percent of total billed charges,,,146.91,,,percent of total billed charges,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,247.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",110.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,22.69,,,percent of total billed charges,,,283.66,,,percent of total billed charges,,,283.66,,,percent of total billed charges,,,,,,,,,,,,,,,283.66,,,percent of total billed charges,,,283.66,,,percent of total billed charges,,,,,,,,,70.54,,,fee schedule,,,282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,212.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",282.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",183.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",212.75,,,percent of total billed charges,,,283.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,283.66,,,percent of total billed charges,,,283.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,22.06,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
REMOVE IMPACTED EAR WAX UNI,2800000100,CDM,761,RC,69210,CPT,5733,APC,,,,outpatient,facility,,,283.66,283.66,66.98,100.64,,,,,,,,71.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,69.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.1,,,fee schedule,,,,,,,,,69.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,69.41,,,fee schedule,,,,,,,,,,,,,,,72.87,,,fee schedule,,,72.88,,,fee schedule,,,,,,,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,72.88,,,fee schedule,,,,,,,,,,,,,,,100.64,,,fee schedule,,,,,,,,,,,,,,,71.49,,,fee schedule,,,,,,,,,,,,,,,66.98,,,fee schedule,,,74.27,,,fee schedule,,,74.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,73.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,86.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,,,,,,,,,,,,,69.41,,,fee schedule,,,,,,,,,,,,,,,69.41,,,fee schedule,,,71.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.59,,,fee schedule,,,69.41,,,fee schedule,,,73.71,,,fee schedule,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,70.54,,,fee schedule,,,,,,,,,70.54,,,fee schedule,,,,,,,,
REMOVE IMPACTED EAR WAX UNI,2800000100,CDM,761,RC,69210,CPT,2005,EAPG,,,,outpatient,facility,,,283.66,283.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IM ADMIN 1ST/ONLY COMPONENT,2800000104,CDM,771,RC,90460,CPT,,,,,,inpatient,facility,,,235.36,235.36,18.83,235.36,,,,,,,,,,,,,,235.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.82,,,percent of total billed charges,,,,,,,,,235.36,,,percent of total billed charges,,,130.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.36,,,percent of total billed charges,,,,,,,,,,,,,,,235.36,,,percent of total billed charges,,,122.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.83,,,percent of total billed charges,,,235.36,,,percent of total billed charges,,,235.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,235.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.27,,,percent of total billed charges,,
IM ADMIN 1ST/ONLY COMPONENT,2800000104,CDM,771,RC,90460,CPT,,,,,,outpatient,facility,,,235.36,235.36,16.13,618.77,,137.45,,,percent of total billed charges,,,45.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,235.36,,,percent of total billed charges,,,41.04,,,fee schedule,,,45.67,,,fee schedule,,,,,,,,,45.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,235.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,86.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,211.82,,,percent of total billed charges,,,,,,,,,235.36,,,percent of total billed charges,,,159.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.76,,,percent of total billed charges,,,,,,,,,,,,,,,123.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",130.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,235.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,122.72,,,percent of total billed charges,,,235.36,,,percent of total billed charges,,,235.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.87,,,percent of total billed charges,,,89.15,,,percent of total billed charges,,,121.89,,,percent of total billed charges,,,,,,,,,,,,,,,47.07,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,36.17,,,fee schedule,,,16.13,,,fee schedule,,,235.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,235.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.83,,,percent of total billed charges,,,235.36,,,percent of total billed charges,,,235.36,,,percent of total billed charges,,,,,,,,,,,,,,,235.36,,,percent of total billed charges,,,235.36,,,percent of total billed charges,,,,,,,,,235.36,,,fee schedule,,,35.55,,,fee schedule,,,,,,,,,,,,,,,31.27,,,fee schedule,,,41.69,,,fee schedule,,,23.11,,,fee schedule,,,176.52,,,percent of total billed charges,,,235.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,235.36,,,percent of total billed charges,,,235.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,165.27,,,percent of total billed charges,,
IM ADMIN 1ST/ONLY COMPONENT,2800000104,CDM,771,RC,90460,CPT,459,EAPG,,,,outpatient,facility,,,235.36,235.36,46.79,68.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.59,,,fee schedule,,,46.79,,,fee schedule,,,60.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,46.79,,,fee schedule,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IM ADMIN EACH ADDL COMPONENT,2800000105,CDM,771,RC,90461,CPT,,,,,,inpatient,facility,,,46.23,46.23,3.7,46.23,,,,,,,,,,,,,,46.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.61,,,percent of total billed charges,,,,,,,,,46.23,,,percent of total billed charges,,,25.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.23,,,percent of total billed charges,,,,,,,,,,,,,,,46.23,,,percent of total billed charges,,,24.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,46.23,,,percent of total billed charges,,,46.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.46,,,percent of total billed charges,,
IM ADMIN EACH ADDL COMPONENT,2800000105,CDM,771,RC,90461,CPT,,,,,,outpatient,facility,,,46.23,46.23,3.7,618.77,,27,,,percent of total billed charges,,,9.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,46.23,,,percent of total billed charges,,,31.19,,,fee schedule,,,34.71,,,fee schedule,,,,,,,,,34.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,46.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,16.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,41.61,,,percent of total billed charges,,,,,,,,,46.23,,,percent of total billed charges,,,31.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.5,,,percent of total billed charges,,,,,,,,,,,,,,,61.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",65.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,46.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.1,,,percent of total billed charges,,,46.23,,,percent of total billed charges,,,46.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.13,,,percent of total billed charges,,,17.51,,,percent of total billed charges,,,23.94,,,percent of total billed charges,,,,,,,,,,,,,,,9.25,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,36.17,,,fee schedule,,,16.13,,,fee schedule,,,46.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.7,,,percent of total billed charges,,,46.23,,,percent of total billed charges,,,46.23,,,percent of total billed charges,,,,,,,,,,,,,,,46.23,,,percent of total billed charges,,,46.23,,,percent of total billed charges,,,,,,,,,46.23,,,fee schedule,,,35.55,,,fee schedule,,,,,,,,,,,,,,,31.27,,,fee schedule,,,41.69,,,fee schedule,,,23.11,,,fee schedule,,,34.67,,,percent of total billed charges,,,46.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,46.23,,,percent of total billed charges,,,46.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.11,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,32.46,,,percent of total billed charges,,
IM ADMIN EACH ADDL COMPONENT,2800000105,CDM,771,RC,90461,CPT,999,EAPG,,,,outpatient,facility,,,46.23,46.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADMIN FLU VIRUS VACCINE,2800000106,CDM,771,RC,90471,CPT,,,,,,inpatient,facility,,,186.49,186.49,14.92,186.49,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.84,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,103.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,97.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.95,,,percent of total billed charges,,
ADMIN FLU VIRUS VACCINE,2800000106,CDM,771,RC,90471,CPT,,,,,,outpatient,facility,,,186.49,186.49,14.92,618.77,,108.91,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,85.56,,,fee schedule,,,82.45,,,fee schedule,,,,,,,,,82.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,167.84,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,126.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.22,,,percent of total billed charges,,,,,,,,,,,,,,,123.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",130.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,97.24,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,70.64,,,percent of total billed charges,,,96.58,,,percent of total billed charges,,,,,,,,,,,,,,,37.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,181.39,,,fee schedule,,,80.87,,,fee schedule,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,84.52,,,fee schedule,,,178.29,,,fee schedule,,,,,,,,,,,,,,,156.78,,,fee schedule,,,186.49,,,fee schedule,,,115.89,,,fee schedule,,,139.87,,,percent of total billed charges,,,186.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,23.59,,,fee schedule,,
ADMIN FLU VIRUS VACCINE,2800000106,CDM,771,RC,90471,CPT,5692,APC,,,,outpatient,facility,,,186.49,186.49,80.26,120.6,,,,,,,,85.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,fee schedule,,,,,,,,,83.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,87.31,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,,,,,,,120.6,,,fee schedule,,,,,,,,,,,,,,,85.66,,,fee schedule,,,,,,,,,,,,,,,80.26,,,fee schedule,,,88.99,,,fee schedule,,,88.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,87.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,85.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.82,,,fee schedule,,,83.17,,,fee schedule,,,88.32,,,fee schedule,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,84.52,,,fee schedule,,,,,,,,,84.52,,,fee schedule,,,,,,,,
ADMIN FLU VIRUS VACCINE,2800000106,CDM,771,RC,90471,CPT,459,EAPG,,,,outpatient,facility,,,186.49,186.49,46.79,68.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.59,,,fee schedule,,,46.79,,,fee schedule,,,60.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,46.79,,,fee schedule,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADMIN FLU VIRUS VACCINE,2800000106,CDM,771,RC,G0008,HCPCS,,,,,,inpatient,facility,,,186.49,186.49,14.92,186.49,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.84,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,103.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,97.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.95,,,percent of total billed charges,,
ADMIN FLU VIRUS VACCINE,2800000106,CDM,771,RC,G0008,HCPCS,,,,,,outpatient,facility,,,186.49,186.49,14.92,618.77,,108.91,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,57.69,,,fee schedule,,,55.59,,,fee schedule,,,,,,,,,55.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,167.84,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,126.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.22,,,percent of total billed charges,,,,,,,,,,,,,,,90.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",95.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,97.24,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,70.64,,,percent of total billed charges,,,96.58,,,percent of total billed charges,,,,,,,,,,,,,,,37.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,116.33,,,fee schedule,,,51.87,,,fee schedule,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,54.79,,,fee schedule,,,114.34,,,fee schedule,,,,,,,,,,,,,,,100.55,,,fee schedule,,,134.06,,,fee schedule,,,74.32,,,fee schedule,,,19.95,,,fee schedule,,,186.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,130.95,,,percent of total billed charges,,
ADMIN FLU VIRUS VACCINE,2800000106,CDM,771,RC,G0008,HCPCS,5691,APC,,,,outpatient,facility,,,186.49,186.49,51.81,77.85,,,,,,,,55.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.23,,,fee schedule,,,,,,,,,53.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,53.69,,,fee schedule,,,,,,,,,,,,,,,56.38,,,fee schedule,,,56.37,,,fee schedule,,,,,,,,,53.69,,,fee schedule,,,53.69,,,fee schedule,,,56.37,,,fee schedule,,,,,,,,,,,,,,,77.85,,,fee schedule,,,,,,,,,,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,51.81,,,fee schedule,,,57.45,,,fee schedule,,,57.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.69,,,fee schedule,,,53.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,56.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,67.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.69,,,fee schedule,,,53.69,,,fee schedule,,,,,,,,,,,,,,,53.69,,,fee schedule,,,,,,,,,,,,,,,53.69,,,fee schedule,,,55.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.58,,,fee schedule,,,53.69,,,fee schedule,,,57.26,,,fee schedule,,,53.69,,,fee schedule,,,53.69,,,fee schedule,,,54.79,,,fee schedule,,,,,,,,,54.79,,,fee schedule,,,,,,,,
ADMIN FLU VIRUS VACCINE,2800000106,CDM,771,RC,G0008,HCPCS,999,EAPG,,,,outpatient,facility,,,186.49,186.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADMIN HEPATITIS B VACCINE,2800000107,CDM,771,RC,90471,CPT,,,,,,inpatient,facility,,,186.49,186.49,14.92,186.49,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.84,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,103.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,97.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.95,,,percent of total billed charges,,
ADMIN HEPATITIS B VACCINE,2800000107,CDM,771,RC,90471,CPT,,,,,,outpatient,facility,,,186.49,186.49,14.92,618.77,,108.91,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,85.56,,,fee schedule,,,82.45,,,fee schedule,,,,,,,,,82.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,167.84,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,126.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.22,,,percent of total billed charges,,,,,,,,,,,,,,,123.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",130.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,97.24,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,70.64,,,percent of total billed charges,,,96.58,,,percent of total billed charges,,,,,,,,,,,,,,,37.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,181.39,,,fee schedule,,,80.87,,,fee schedule,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,84.52,,,fee schedule,,,178.29,,,fee schedule,,,,,,,,,,,,,,,156.78,,,fee schedule,,,186.49,,,fee schedule,,,115.89,,,fee schedule,,,139.87,,,percent of total billed charges,,,186.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,23.59,,,fee schedule,,
ADMIN HEPATITIS B VACCINE,2800000107,CDM,771,RC,90471,CPT,5692,APC,,,,outpatient,facility,,,186.49,186.49,80.26,120.6,,,,,,,,85.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,fee schedule,,,,,,,,,83.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,87.31,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,,,,,,,120.6,,,fee schedule,,,,,,,,,,,,,,,85.66,,,fee schedule,,,,,,,,,,,,,,,80.26,,,fee schedule,,,88.99,,,fee schedule,,,88.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,87.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,85.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.82,,,fee schedule,,,83.17,,,fee schedule,,,88.32,,,fee schedule,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,84.52,,,fee schedule,,,,,,,,,84.52,,,fee schedule,,,,,,,,
ADMIN HEPATITIS B VACCINE,2800000107,CDM,771,RC,90471,CPT,459,EAPG,,,,outpatient,facility,,,186.49,186.49,46.79,68.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.59,,,fee schedule,,,46.79,,,fee schedule,,,60.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,46.79,,,fee schedule,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADMIN HEPATITIS B VACCINE,2800000107,CDM,771,RC,G0010,HCPCS,,,,,,inpatient,facility,,,186.49,186.49,14.92,186.49,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.84,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,103.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,97.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.95,,,percent of total billed charges,,
ADMIN HEPATITIS B VACCINE,2800000107,CDM,771,RC,G0010,HCPCS,,,,,,outpatient,facility,,,186.49,186.49,14.92,618.77,,108.91,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,57.69,,,fee schedule,,,55.59,,,fee schedule,,,,,,,,,55.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,167.84,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,126.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.22,,,percent of total billed charges,,,,,,,,,,,,,,,123.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",130.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,97.24,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,70.64,,,percent of total billed charges,,,96.58,,,percent of total billed charges,,,,,,,,,,,,,,,37.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,116.33,,,fee schedule,,,51.87,,,fee schedule,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,54.79,,,fee schedule,,,114.34,,,fee schedule,,,,,,,,,,,,,,,100.55,,,fee schedule,,,134.06,,,fee schedule,,,74.32,,,fee schedule,,,19.95,,,fee schedule,,,186.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,130.95,,,percent of total billed charges,,
ADMIN HEPATITIS B VACCINE,2800000107,CDM,771,RC,G0010,HCPCS,5691,APC,,,,outpatient,facility,,,186.49,186.49,51.81,77.85,,,,,,,,55.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.23,,,fee schedule,,,,,,,,,53.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,53.69,,,fee schedule,,,,,,,,,,,,,,,56.38,,,fee schedule,,,56.37,,,fee schedule,,,,,,,,,53.69,,,fee schedule,,,53.69,,,fee schedule,,,56.37,,,fee schedule,,,,,,,,,,,,,,,77.85,,,fee schedule,,,,,,,,,,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,51.81,,,fee schedule,,,57.45,,,fee schedule,,,57.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.69,,,fee schedule,,,53.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,56.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,67.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.69,,,fee schedule,,,53.69,,,fee schedule,,,,,,,,,,,,,,,53.69,,,fee schedule,,,,,,,,,,,,,,,53.69,,,fee schedule,,,55.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.58,,,fee schedule,,,53.69,,,fee schedule,,,57.26,,,fee schedule,,,53.69,,,fee schedule,,,53.69,,,fee schedule,,,54.79,,,fee schedule,,,,,,,,,54.79,,,fee schedule,,,,,,,,
ADMIN HEPATITIS B VACCINE,2800000107,CDM,771,RC,G0010,HCPCS,999,EAPG,,,,outpatient,facility,,,186.49,186.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADMIN PNEUMONIA VACCINE,2800000108,CDM,771,RC,90471,CPT,,,,,,inpatient,facility,,,186.49,186.49,14.92,186.49,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.84,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,103.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,97.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.95,,,percent of total billed charges,,
ADMIN PNEUMONIA VACCINE,2800000108,CDM,771,RC,90471,CPT,,,,,,outpatient,facility,,,186.49,186.49,14.92,618.77,,108.91,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,85.56,,,fee schedule,,,82.45,,,fee schedule,,,,,,,,,82.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,167.84,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,126.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.22,,,percent of total billed charges,,,,,,,,,,,,,,,123.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",130.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,97.24,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,70.64,,,percent of total billed charges,,,96.58,,,percent of total billed charges,,,,,,,,,,,,,,,37.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,181.39,,,fee schedule,,,80.87,,,fee schedule,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,84.52,,,fee schedule,,,178.29,,,fee schedule,,,,,,,,,,,,,,,156.78,,,fee schedule,,,186.49,,,fee schedule,,,115.89,,,fee schedule,,,139.87,,,percent of total billed charges,,,186.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,23.59,,,fee schedule,,
ADMIN PNEUMONIA VACCINE,2800000108,CDM,771,RC,90471,CPT,5692,APC,,,,outpatient,facility,,,186.49,186.49,80.26,120.6,,,,,,,,85.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,fee schedule,,,,,,,,,83.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,87.31,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,,,,,,,120.6,,,fee schedule,,,,,,,,,,,,,,,85.66,,,fee schedule,,,,,,,,,,,,,,,80.26,,,fee schedule,,,88.99,,,fee schedule,,,88.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,87.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,85.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.82,,,fee schedule,,,83.17,,,fee schedule,,,88.32,,,fee schedule,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,84.52,,,fee schedule,,,,,,,,,84.52,,,fee schedule,,,,,,,,
ADMIN PNEUMONIA VACCINE,2800000108,CDM,771,RC,90471,CPT,459,EAPG,,,,outpatient,facility,,,186.49,186.49,46.79,68.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.59,,,fee schedule,,,46.79,,,fee schedule,,,60.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,46.79,,,fee schedule,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADMIN PNEUMONIA VACCINE,2800000108,CDM,771,RC,G0009,HCPCS,,,,,,inpatient,facility,,,186.49,186.49,14.92,186.49,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.84,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,103.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,97.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.95,,,percent of total billed charges,,
ADMIN PNEUMONIA VACCINE,2800000108,CDM,771,RC,G0009,HCPCS,,,,,,outpatient,facility,,,186.49,186.49,14.92,618.77,,108.91,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,57.69,,,fee schedule,,,55.59,,,fee schedule,,,,,,,,,55.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,167.84,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,126.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.22,,,percent of total billed charges,,,,,,,,,,,,,,,90.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",95.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,97.24,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,70.64,,,percent of total billed charges,,,96.58,,,percent of total billed charges,,,,,,,,,,,,,,,37.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,116.33,,,fee schedule,,,51.87,,,fee schedule,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,54.79,,,fee schedule,,,114.34,,,fee schedule,,,,,,,,,,,,,,,100.55,,,fee schedule,,,134.06,,,fee schedule,,,74.32,,,fee schedule,,,19.95,,,fee schedule,,,186.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,130.95,,,percent of total billed charges,,
ADMIN PNEUMONIA VACCINE,2800000108,CDM,771,RC,G0009,HCPCS,5691,APC,,,,outpatient,facility,,,186.49,186.49,51.81,77.85,,,,,,,,55.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.23,,,fee schedule,,,,,,,,,53.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,53.69,,,fee schedule,,,,,,,,,,,,,,,56.38,,,fee schedule,,,56.37,,,fee schedule,,,,,,,,,53.69,,,fee schedule,,,53.69,,,fee schedule,,,56.37,,,fee schedule,,,,,,,,,,,,,,,77.85,,,fee schedule,,,,,,,,,,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,51.81,,,fee schedule,,,57.45,,,fee schedule,,,57.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.69,,,fee schedule,,,53.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,56.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,67.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.69,,,fee schedule,,,53.69,,,fee schedule,,,,,,,,,,,,,,,53.69,,,fee schedule,,,,,,,,,,,,,,,53.69,,,fee schedule,,,55.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.58,,,fee schedule,,,53.69,,,fee schedule,,,57.26,,,fee schedule,,,53.69,,,fee schedule,,,53.69,,,fee schedule,,,54.79,,,fee schedule,,,,,,,,,54.79,,,fee schedule,,,,,,,,
ADMIN PNEUMONIA VACCINE,2800000108,CDM,771,RC,G0009,HCPCS,459,EAPG,,,,outpatient,facility,,,186.49,186.49,46.79,68.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.59,,,fee schedule,,,46.79,,,fee schedule,,,60.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,46.79,,,fee schedule,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMMUNIZATION ADMIN 1 VACCINE,2800000109,CDM,771,RC,90471,CPT,,,,,,inpatient,facility,,,186.49,186.49,14.92,186.49,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.84,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,103.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,97.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.95,,,percent of total billed charges,,
IMMUNIZATION ADMIN 1 VACCINE,2800000109,CDM,771,RC,90471,CPT,,,,,,outpatient,facility,,,186.49,186.49,14.92,618.77,,108.91,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,85.56,,,fee schedule,,,82.45,,,fee schedule,,,,,,,,,82.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,167.84,,,percent of total billed charges,,,,,,,,,186.49,,,percent of total billed charges,,,126.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.22,,,percent of total billed charges,,,,,,,,,,,,,,,123.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",130.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,97.24,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,70.64,,,percent of total billed charges,,,96.58,,,percent of total billed charges,,,,,,,,,,,,,,,37.3,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,181.39,,,fee schedule,,,80.87,,,fee schedule,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,84.52,,,fee schedule,,,178.29,,,fee schedule,,,,,,,,,,,,,,,156.78,,,fee schedule,,,186.49,,,fee schedule,,,115.89,,,fee schedule,,,139.87,,,percent of total billed charges,,,186.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,186.49,,,percent of total billed charges,,,186.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,23.59,,,fee schedule,,
IMMUNIZATION ADMIN 1 VACCINE,2800000109,CDM,771,RC,90471,CPT,5692,APC,,,,outpatient,facility,,,186.49,186.49,80.26,120.6,,,,,,,,85.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,fee schedule,,,,,,,,,83.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,87.31,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,,,,,,,120.6,,,fee schedule,,,,,,,,,,,,,,,85.66,,,fee schedule,,,,,,,,,,,,,,,80.26,,,fee schedule,,,88.99,,,fee schedule,,,88.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,87.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,85.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.82,,,fee schedule,,,83.17,,,fee schedule,,,88.32,,,fee schedule,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,84.52,,,fee schedule,,,,,,,,,84.52,,,fee schedule,,,,,,,,
IMMUNIZATION ADMIN 1 VACCINE,2800000109,CDM,771,RC,90471,CPT,459,EAPG,,,,outpatient,facility,,,186.49,186.49,46.79,68.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.59,,,fee schedule,,,46.79,,,fee schedule,,,60.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,46.79,,,fee schedule,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMMUNZTN ADM; EA ADDTL VAC,2800000113,CDM,771,RC,90472,CPT,,,,,,inpatient,facility,,,20.83,20.83,1.67,20.83,,,,,,,,,,,,,,20.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.75,,,percent of total billed charges,,,,,,,,,20.83,,,percent of total billed charges,,,11.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.83,,,percent of total billed charges,,,,,,,,,,,,,,,20.83,,,percent of total billed charges,,,10.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,20.83,,,percent of total billed charges,,,20.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.63,,,percent of total billed charges,,
IMMUNZTN ADM; EA ADDTL VAC,2800000113,CDM,771,RC,90472,CPT,,,,,,outpatient,facility,,,20.83,20.83,1.67,618.77,,12.16,,,percent of total billed charges,,,4.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,20.83,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,20.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,7.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,18.75,,,percent of total billed charges,,,,,,,,,20.83,,,percent of total billed charges,,,14.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,20.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.86,,,percent of total billed charges,,,20.83,,,percent of total billed charges,,,20.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.83,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,10.79,,,percent of total billed charges,,,,,,,,,,,,,,,4.17,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,20.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.67,,,percent of total billed charges,,,20.83,,,percent of total billed charges,,,20.83,,,percent of total billed charges,,,,,,,,,,,,,,,20.83,,,percent of total billed charges,,,20.83,,,percent of total billed charges,,,,,,,,,20.83,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,15.62,,,percent of total billed charges,,,20.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,20.83,,,percent of total billed charges,,,20.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,11.4,,,fee schedule,,
IMMUNZTN ADM; EA ADDTL VAC,2800000113,CDM,771,RC,90472,CPT,459,EAPG,,,,outpatient,facility,,,20.83,20.83,46.79,68.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.59,,,fee schedule,,,46.79,,,fee schedule,,,60.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,46.79,,,fee schedule,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
12 LEAD EKG; TRACING ONLY,2800000114,CDM,730,RC,93005,CPT,,,,,,inpatient,facility,,,181.09,181.09,14.49,181.09,,,,,,,,,,,,,,181.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.98,,,percent of total billed charges,,,,,,,,,181.09,,,percent of total billed charges,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.09,,,percent of total billed charges,,,,,,,,,,,,,,,181.09,,,percent of total billed charges,,,94.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,181.09,,,percent of total billed charges,,,181.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,181.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.16,,,percent of total billed charges,,
12 LEAD EKG; TRACING ONLY,2800000114,CDM,730,RC,93005,CPT,,,,,,outpatient,facility,,,181.09,181.09,14.49,618.77,,105.76,,,percent of total billed charges,,,,,,,,,181.09,,,percent of total billed charges,,,91.21,,,fee schedule,,,101.5,,,fee schedule,,,,,,,,,101.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,181.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,162.98,,,percent of total billed charges,,,,,,,,,181.09,,,percent of total billed charges,,,122.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.08,,,percent of total billed charges,,,,,,,,,,,,,,,163.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",172.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,181.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.42,,,percent of total billed charges,,,181.09,,,percent of total billed charges,,,181.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.63,,,percent of total billed charges,,,68.6,,,percent of total billed charges,,,93.79,,,percent of total billed charges,,,,,,,,,,,,,,,36.22,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,157.8,,,fee schedule,,,70.36,,,fee schedule,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,181.09,,,percent of total billed charges,,,181.09,,,percent of total billed charges,,,,,,,,,,,,,,,181.09,,,percent of total billed charges,,,181.09,,,percent of total billed charges,,,,,,,,,70.54,,,fee schedule,,,155.1,,,fee schedule,,,,,,,,,,,,,,,136.39,,,fee schedule,,,181.09,,,fee schedule,,,100.82,,,fee schedule,,,66.47,,,fee schedule,,,181.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,181.09,,,percent of total billed charges,,,181.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,17.17,,,fee schedule,,
12 LEAD EKG; TRACING ONLY,2800000114,CDM,730,RC,93005,CPT,5733,APC,,,,outpatient,facility,,,181.09,181.09,66.98,100.64,,,,,,,,71.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,69.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.1,,,fee schedule,,,,,,,,,69.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,69.41,,,fee schedule,,,,,,,,,,,,,,,72.87,,,fee schedule,,,72.88,,,fee schedule,,,,,,,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,72.88,,,fee schedule,,,,,,,,,,,,,,,100.64,,,fee schedule,,,,,,,,,,,,,,,71.49,,,fee schedule,,,,,,,,,,,,,,,66.98,,,fee schedule,,,74.27,,,fee schedule,,,74.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,73.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,86.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,,,,,,,,,,,,,69.41,,,fee schedule,,,,,,,,,,,,,,,69.41,,,fee schedule,,,71.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.59,,,fee schedule,,,69.41,,,fee schedule,,,73.71,,,fee schedule,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,70.54,,,fee schedule,,,,,,,,,70.54,,,fee schedule,,,,,,,,
12 LEAD EKG; TRACING ONLY,2800000114,CDM,730,RC,93005,CPT,413,EAPG,,,,outpatient,facility,,,181.09,181.09,24.01,35.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.2,,,fee schedule,,,24.01,,,fee schedule,,,31.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.01,,,fee schedule,,,24.01,,,fee schedule,,,24.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,24.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RHYTHM ECG 1-3 LEADS TRACING,2800000115,CDM,730,RC,93041,CPT,,,,,,inpatient,facility,,,151.87,151.87,12.15,151.87,,,,,,,,,,,,,,151.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.68,,,percent of total billed charges,,,,,,,,,151.87,,,percent of total billed charges,,,84.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.87,,,percent of total billed charges,,,,,,,,,,,,,,,151.87,,,percent of total billed charges,,,79.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.15,,,percent of total billed charges,,,151.87,,,percent of total billed charges,,,151.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,151.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.64,,,percent of total billed charges,,
RHYTHM ECG 1-3 LEADS TRACING,2800000115,CDM,730,RC,93041,CPT,,,,,,outpatient,facility,,,151.87,151.87,7.2,618.77,,88.69,,,percent of total billed charges,,,,,,,,,151.87,,,percent of total billed charges,,,91.21,,,fee schedule,,,101.5,,,fee schedule,,,,,,,,,101.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,151.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,136.68,,,percent of total billed charges,,,,,,,,,151.87,,,percent of total billed charges,,,102.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.64,,,percent of total billed charges,,,,,,,,,,,,,,,89.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",94.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,151.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.19,,,percent of total billed charges,,,151.87,,,percent of total billed charges,,,151.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.42,,,percent of total billed charges,,,57.53,,,percent of total billed charges,,,78.65,,,percent of total billed charges,,,,,,,,,,,,,,,30.37,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,151.87,,,fee schedule,,,70.36,,,fee schedule,,,,,,,,,,,,,,,12.15,,,percent of total billed charges,,,151.87,,,percent of total billed charges,,,151.87,,,percent of total billed charges,,,,,,,,,,,,,,,151.87,,,percent of total billed charges,,,151.87,,,percent of total billed charges,,,,,,,,,70.54,,,fee schedule,,,151.87,,,fee schedule,,,,,,,,,,,,,,,136.39,,,fee schedule,,,151.87,,,fee schedule,,,100.82,,,fee schedule,,,66.47,,,fee schedule,,,151.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,151.87,,,percent of total billed charges,,,151.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,7.2,,,fee schedule,,
RHYTHM ECG 1-3 LEADS TRACING,2800000115,CDM,730,RC,93041,CPT,5733,APC,,,,outpatient,facility,,,151.87,151.87,66.98,100.64,,,,,,,,71.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,69.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.1,,,fee schedule,,,,,,,,,69.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,69.41,,,fee schedule,,,,,,,,,,,,,,,72.87,,,fee schedule,,,72.88,,,fee schedule,,,,,,,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,72.88,,,fee schedule,,,,,,,,,,,,,,,100.64,,,fee schedule,,,,,,,,,,,,,,,71.49,,,fee schedule,,,,,,,,,,,,,,,66.98,,,fee schedule,,,74.27,,,fee schedule,,,74.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,73.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,86.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,,,,,,,,,,,,,69.41,,,fee schedule,,,,,,,,,,,,,,,69.41,,,fee schedule,,,71.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.59,,,fee schedule,,,69.41,,,fee schedule,,,73.71,,,fee schedule,,,69.41,,,fee schedule,,,69.41,,,fee schedule,,,70.54,,,fee schedule,,,,,,,,,70.54,,,fee schedule,,,,,,,,
RHYTHM ECG 1-3 LEADS TRACING,2800000115,CDM,730,RC,93041,CPT,413,EAPG,,,,outpatient,facility,,,151.87,151.87,24.01,35.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.2,,,fee schedule,,,24.01,,,fee schedule,,,31.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.01,,,fee schedule,,,24.01,,,fee schedule,,,24.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,24.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPIROMETRY,2800000116,CDM,460,RC,94010,CPT,,,,,,inpatient,facility,,,413.25,413.25,33.06,413.25,,,,,,,,,,,,,,413.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.93,,,percent of total billed charges,,,,,,,,,413.25,,,percent of total billed charges,,,228.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,413.25,,,percent of total billed charges,,,,,,,,,,,,,,,413.25,,,percent of total billed charges,,,215.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.06,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,413.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.18,,,percent of total billed charges,,
SPIROMETRY,2800000116,CDM,460,RC,94010,CPT,,,,,,outpatient,facility,,,413.25,413.25,33.06,618.77,,241.34,,,percent of total billed charges,,,,,,,,,413.25,,,percent of total billed charges,,,221.86,,,fee schedule,,,246.89,,,fee schedule,,,,,,,,,246.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,413.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,371.93,,,percent of total billed charges,,,,,,,,,413.25,,,percent of total billed charges,,,279.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,317.38,,,percent of total billed charges,,,,,,,,,,,,,,,378.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",400.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,413.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,215.47,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,314.07,,,percent of total billed charges,,,156.54,,,percent of total billed charges,,,214.02,,,percent of total billed charges,,,,,,,,,,,,,,,82.65,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,400.77,,,fee schedule,,,178.68,,,fee schedule,,,,,,,,,,,,,,,33.06,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,,,,,,,,,,,,,413.25,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,,,,,,,185.81,,,fee schedule,,,393.91,,,fee schedule,,,,,,,,,,,,,,,346.4,,,fee schedule,,,413.25,,,fee schedule,,,256.04,,,fee schedule,,,165.06,,,fee schedule,,,413.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,413.25,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,39.38,,,fee schedule,,
SPIROMETRY,2800000116,CDM,460,RC,94010,CPT,5721,APC,,,,outpatient,facility,,,413.25,413.25,176.44,265.12,,,,,,,,188.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,182.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.67,,,fee schedule,,,,,,,,,182.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,182.84,,,fee schedule,,,,,,,,,,,,,,,191.94,,,fee schedule,,,191.98,,,fee schedule,,,,,,,,,182.84,,,fee schedule,,,182.84,,,fee schedule,,,191.98,,,fee schedule,,,,,,,,,,,,,,,265.12,,,fee schedule,,,,,,,,,,,,,,,188.3,,,fee schedule,,,,,,,,,,,,,,,176.44,,,fee schedule,,,195.64,,,fee schedule,,,195.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.84,,,fee schedule,,,182.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,193.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,228.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,182.84,,,fee schedule,,,182.84,,,fee schedule,,,,,,,,,,,,,,,182.84,,,fee schedule,,,,,,,,,,,,,,,182.84,,,fee schedule,,,188.33,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.81,,,fee schedule,,,182.84,,,fee schedule,,,194.17,,,fee schedule,,,182.84,,,fee schedule,,,182.84,,,fee schedule,,,185.81,,,fee schedule,,,,,,,,,185.81,,,fee schedule,,,,,,,,
SPIROMETRY,2800000116,CDM,460,RC,94010,CPT,412,EAPG,,,,outpatient,facility,,,413.25,413.25,148.99,218.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.42,,,fee schedule,,,148.99,,,fee schedule,,,194.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.99,,,fee schedule,,,148.99,,,fee schedule,,,148.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,148.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AIRWAY INHALATION TREATMENT,2800000117,CDM,410,RC,94640,CPT,,,,,,inpatient,facility,,,262.79,262.79,21.02,262.79,,,,,,,,,,,,,,262.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.51,,,percent of total billed charges,,,,,,,,,262.79,,,percent of total billed charges,,,145.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.79,,,percent of total billed charges,,,,,,,,,,,,,,,262.79,,,percent of total billed charges,,,137.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.02,,,percent of total billed charges,,,262.79,,,percent of total billed charges,,,262.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,262.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.53,,,percent of total billed charges,,
AIRWAY INHALATION TREATMENT,2800000117,CDM,410,RC,94640,CPT,,,,,,outpatient,facility,,,262.79,262.79,16.25,618.77,,153.47,,,percent of total billed charges,,,,,,,,,262.79,,,percent of total billed charges,,,312.67,,,fee schedule,,,347.95,,,fee schedule,,,,,,,,,347.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,262.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,236.51,,,percent of total billed charges,,,,,,,,,262.79,,,percent of total billed charges,,,177.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.82,,,percent of total billed charges,,,,,,,,,,,,,,,436.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",461.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,262.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.02,,,percent of total billed charges,,,262.79,,,percent of total billed charges,,,262.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.72,,,percent of total billed charges,,,99.54,,,percent of total billed charges,,,136.1,,,percent of total billed charges,,,,,,,,,,,,,,,52.56,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,262.79,,,fee schedule,,,232.47,,,fee schedule,,,,,,,,,,,,,,,21.02,,,percent of total billed charges,,,262.79,,,percent of total billed charges,,,262.79,,,percent of total billed charges,,,,,,,,,,,,,,,262.79,,,percent of total billed charges,,,262.79,,,percent of total billed charges,,,,,,,,,241.54,,,fee schedule,,,262.79,,,fee schedule,,,,,,,,,,,,,,,262.79,,,fee schedule,,,262.79,,,fee schedule,,,262.79,,,fee schedule,,,56.29,,,fee schedule,,,262.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,262.79,,,percent of total billed charges,,,262.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,16.25,,,fee schedule,,
AIRWAY INHALATION TREATMENT,2800000117,CDM,410,RC,94640,CPT,5791,APC,,,,outpatient,facility,,,262.79,262.79,229.36,344.64,,,,,,,,244.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,237.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.06,,,fee schedule,,,,,,,,,237.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,237.68,,,fee schedule,,,,,,,,,,,,,,,249.51,,,fee schedule,,,249.56,,,fee schedule,,,,,,,,,237.68,,,fee schedule,,,237.68,,,fee schedule,,,249.56,,,fee schedule,,,,,,,,,,,,,,,344.64,,,fee schedule,,,,,,,,,,,,,,,244.78,,,fee schedule,,,,,,,,,,,,,,,229.36,,,fee schedule,,,254.32,,,fee schedule,,,253.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.68,,,fee schedule,,,237.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,251.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,297.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,297.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,237.68,,,fee schedule,,,237.68,,,fee schedule,,,,,,,,,,,,,,,237.68,,,fee schedule,,,,,,,,,,,,,,,237.68,,,fee schedule,,,244.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.04,,,fee schedule,,,237.68,,,fee schedule,,,252.41,,,fee schedule,,,237.68,,,fee schedule,,,237.68,,,fee schedule,,,241.54,,,fee schedule,,,,,,,,,241.54,,,fee schedule,,,,,,,,
AIRWAY INHALATION TREATMENT,2800000117,CDM,410,RC,94640,CPT,412,EAPG,,,,outpatient,facility,,,262.79,262.79,148.99,218.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.42,,,fee schedule,,,148.99,,,fee schedule,,,194.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.99,,,fee schedule,,,148.99,,,fee schedule,,,148.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,148.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PULSE OX SGL,2800000118,CDM,460,RC,94760,CPT,,,,,,inpatient,facility,,,8.32,8.32,0.67,8.32,,,,,,,,,,,,,,8.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,8.32,,,percent of total billed charges,,,4.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.32,,,percent of total billed charges,,,,,,,,,,,,,,,8.32,,,percent of total billed charges,,,4.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,8.32,,,percent of total billed charges,,,8.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,,percent of total billed charges,,
PULSE OX SGL,2800000118,CDM,460,RC,94760,CPT,,,,,,outpatient,facility,,,8.32,8.32,0.67,618.77,,4.86,,,percent of total billed charges,,,1.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,8.32,,,percent of total billed charges,,,7.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,7.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,7.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,3.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,7.49,,,percent of total billed charges,,,,,,,,,8.32,,,percent of total billed charges,,,5.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,8.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.34,,,percent of total billed charges,,,8.32,,,percent of total billed charges,,,8.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.32,,,percent of total billed charges,,,3.15,,,percent of total billed charges,,,4.31,,,percent of total billed charges,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,8.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.67,,,percent of total billed charges,,,8.32,,,percent of total billed charges,,,8.32,,,percent of total billed charges,,,,,,,,,,,,,,,8.32,,,percent of total billed charges,,,8.32,,,percent of total billed charges,,,,,,,,,8.32,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,6.24,,,percent of total billed charges,,,8.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,8.32,,,percent of total billed charges,,,8.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,2.9,,,fee schedule,,
PULSE OX SGL,2800000118,CDM,460,RC,94760,CPT,2004,EAPG,,,,outpatient,facility,,,8.32,8.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDRATION IV INF INIT 31-60,2800000120,CDM,260,RC,96360,CPT,,,,,,inpatient,facility,,,511.64,511.64,40.93,511.64,,,,,,,,,,,,,,511.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,460.48,,,percent of total billed charges,,,,,,,,,511.64,,,percent of total billed charges,,,283.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.64,,,percent of total billed charges,,,,,,,,,,,,,,,511.64,,,percent of total billed charges,,,266.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.93,,,percent of total billed charges,,,511.64,,,percent of total billed charges,,,511.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,511.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.27,,,percent of total billed charges,,
HYDRATION IV INF INIT 31-60,2800000120,CDM,260,RC,96360,CPT,,,,,,outpatient,facility,,,511.64,511.64,40.93,618.77,,298.8,,,percent of total billed charges,,,,,,,,,511.64,,,percent of total billed charges,,,305.45,,,fee schedule,,,339.91,,,fee schedule,,,,,,,,,339.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,511.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,460.48,,,percent of total billed charges,,,,,,,,,511.64,,,percent of total billed charges,,,346.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.94,,,percent of total billed charges,,,,,,,,,,,,,,,269.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",285.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,511.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.77,,,percent of total billed charges,,,511.64,,,percent of total billed charges,,,511.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.85,,,percent of total billed charges,,,193.81,,,percent of total billed charges,,,264.98,,,percent of total billed charges,,,,,,,,,,,,,,,102.33,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,511.64,,,fee schedule,,,252.99,,,fee schedule,,,,,,,,,,,,,,,40.93,,,percent of total billed charges,,,511.64,,,percent of total billed charges,,,511.64,,,percent of total billed charges,,,,,,,,,,,,,,,511.64,,,percent of total billed charges,,,511.64,,,percent of total billed charges,,,,,,,,,250.21,,,fee schedule,,,511.64,,,fee schedule,,,,,,,,,,,,,,,490.43,,,fee schedule,,,511.64,,,fee schedule,,,362.51,,,fee schedule,,,186.83,,,fee schedule,,,511.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,511.64,,,percent of total billed charges,,,511.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,359.27,,,percent of total billed charges,,
HYDRATION IV INF INIT 31-60,2800000120,CDM,260,RC,96360,CPT,5693,APC,,,,outpatient,facility,,,511.64,511.64,237.59,357,,,,,,,,253.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,246.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.67,,,fee schedule,,,,,,,,,246.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,246.21,,,fee schedule,,,,,,,,,,,,,,,258.47,,,fee schedule,,,258.52,,,fee schedule,,,,,,,,,246.21,,,fee schedule,,,246.21,,,fee schedule,,,258.52,,,fee schedule,,,,,,,,,,,,,,,357,,,fee schedule,,,,,,,,,,,,,,,253.57,,,fee schedule,,,,,,,,,,,,,,,237.59,,,fee schedule,,,263.44,,,fee schedule,,,262.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.21,,,fee schedule,,,246.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,260.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,307.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,246.21,,,fee schedule,,,246.21,,,fee schedule,,,,,,,,,,,,,,,246.21,,,fee schedule,,,,,,,,,,,,,,,246.21,,,fee schedule,,,253.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.42,,,fee schedule,,,246.21,,,fee schedule,,,261.47,,,fee schedule,,,246.21,,,fee schedule,,,246.21,,,fee schedule,,,250.21,,,fee schedule,,,,,,,,,250.21,,,fee schedule,,,,,,,,
HYDRATION IV INF INIT 31-60,2800000120,CDM,260,RC,96360,CPT,111,EAPG,,,,outpatient,facility,,,511.64,511.64,248.41,364.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.17,,,fee schedule,,,248.41,,,fee schedule,,,323.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,248.41,,,fee schedule,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDRATE IV INFUSION ADD-ON,2800000121,CDM,260,RC,96361,CPT,,,,,,inpatient,facility,,,127.18,127.18,10.17,127.18,,,,,,,,,,,,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.46,,,percent of total billed charges,,,,,,,,,127.18,,,percent of total billed charges,,,70.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,127.18,,,percent of total billed charges,,,66.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.17,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.31,,,percent of total billed charges,,
HYDRATE IV INFUSION ADD-ON,2800000121,CDM,260,RC,96361,CPT,,,,,,outpatient,facility,,,127.18,127.18,10.17,618.77,,74.27,,,percent of total billed charges,,,,,,,,,127.18,,,percent of total billed charges,,,61.82,,,fee schedule,,,68.79,,,fee schedule,,,,,,,,,68.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,114.46,,,percent of total billed charges,,,,,,,,,127.18,,,percent of total billed charges,,,86.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.67,,,percent of total billed charges,,,,,,,,,,,,,,,90.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",95.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.31,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.66,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,65.87,,,percent of total billed charges,,,,,,,,,,,,,,,25.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,116.33,,,fee schedule,,,51.87,,,fee schedule,,,,,,,,,,,,,,,10.17,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,127.18,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,,,,,,,54.79,,,fee schedule,,,114.34,,,fee schedule,,,,,,,,,,,,,,,100.55,,,fee schedule,,,127.18,,,fee schedule,,,74.32,,,fee schedule,,,95.39,,,percent of total billed charges,,,127.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,127.18,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,89.31,,,percent of total billed charges,,
HYDRATE IV INFUSION ADD-ON,2800000121,CDM,260,RC,96361,CPT,5691,APC,,,,outpatient,facility,,,127.18,127.18,52.02,78.17,,,,,,,,55.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.45,,,fee schedule,,,,,,,,,53.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,53.91,,,fee schedule,,,,,,,,,,,,,,,56.6,,,fee schedule,,,56.61,,,fee schedule,,,,,,,,,53.91,,,fee schedule,,,53.91,,,fee schedule,,,56.61,,,fee schedule,,,,,,,,,,,,,,,78.17,,,fee schedule,,,,,,,,,,,,,,,55.52,,,fee schedule,,,,,,,,,,,,,,,52.02,,,fee schedule,,,57.68,,,fee schedule,,,57.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.91,,,fee schedule,,,53.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,56.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,67.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.91,,,fee schedule,,,53.91,,,fee schedule,,,,,,,,,,,,,,,53.91,,,fee schedule,,,,,,,,,,,,,,,53.91,,,fee schedule,,,55.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.58,,,fee schedule,,,53.91,,,fee schedule,,,57.26,,,fee schedule,,,53.91,,,fee schedule,,,53.91,,,fee schedule,,,54.79,,,fee schedule,,,,,,,,,54.79,,,fee schedule,,,,,,,,
HYDRATE IV INFUSION ADD-ON,2800000121,CDM,260,RC,96361,CPT,110,EAPG,,,,outpatient,facility,,,127.18,127.18,551.75,808.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,808.87,,,fee schedule,,,551.75,,,fee schedule,,,719.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.75,,,fee schedule,,,551.75,,,fee schedule,,,551.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THER/PRO/DX IV INF INIT =<1 HR,2800000123,CDM,260,RC,96365,CPT,,,,,,inpatient,facility,,,596.44,596.44,47.72,596.44,,,,,,,,,,,,,,596.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,536.8,,,percent of total billed charges,,,,,,,,,596.44,,,percent of total billed charges,,,330.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,596.44,,,percent of total billed charges,,,,,,,,,,,,,,,596.44,,,percent of total billed charges,,,310.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.72,,,percent of total billed charges,,,596.44,,,percent of total billed charges,,,596.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,596.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.82,,,percent of total billed charges,,
THER/PRO/DX IV INF INIT =<1 HR,2800000123,CDM,260,RC,96365,CPT,,,,,,outpatient,facility,,,596.44,596.44,47.72,618.77,,348.32,,,percent of total billed charges,,,,,,,,,596.44,,,percent of total billed charges,,,305.45,,,fee schedule,,,339.91,,,fee schedule,,,,,,,,,339.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,596.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,536.8,,,percent of total billed charges,,,,,,,,,596.44,,,percent of total billed charges,,,403.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.07,,,percent of total billed charges,,,,,,,,,,,,,,,505.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",535.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,596.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,310.98,,,percent of total billed charges,,,596.44,,,percent of total billed charges,,,596.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.29,,,percent of total billed charges,,,225.93,,,percent of total billed charges,,,308.9,,,percent of total billed charges,,,,,,,,,,,,,,,119.29,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,567.42,,,fee schedule,,,252.99,,,fee schedule,,,,,,,,,,,,,,,47.72,,,percent of total billed charges,,,596.44,,,percent of total billed charges,,,596.44,,,percent of total billed charges,,,,,,,,,,,,,,,596.44,,,percent of total billed charges,,,596.44,,,percent of total billed charges,,,,,,,,,250.21,,,fee schedule,,,557.7,,,fee schedule,,,,,,,,,,,,,,,490.43,,,fee schedule,,,596.44,,,fee schedule,,,362.51,,,fee schedule,,,312.94,,,fee schedule,,,596.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,596.44,,,percent of total billed charges,,,596.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,418.82,,,percent of total billed charges,,
THER/PRO/DX IV INF INIT =<1 HR,2800000123,CDM,260,RC,96365,CPT,5693,APC,,,,outpatient,facility,,,596.44,596.44,237.59,357,,,,,,,,253.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,246.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.67,,,fee schedule,,,,,,,,,246.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,246.21,,,fee schedule,,,,,,,,,,,,,,,258.47,,,fee schedule,,,258.52,,,fee schedule,,,,,,,,,246.21,,,fee schedule,,,246.21,,,fee schedule,,,258.52,,,fee schedule,,,,,,,,,,,,,,,357,,,fee schedule,,,,,,,,,,,,,,,253.57,,,fee schedule,,,,,,,,,,,,,,,237.59,,,fee schedule,,,263.44,,,fee schedule,,,262.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.21,,,fee schedule,,,246.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,260.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,307.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,246.21,,,fee schedule,,,246.21,,,fee schedule,,,,,,,,,,,,,,,246.21,,,fee schedule,,,,,,,,,,,,,,,246.21,,,fee schedule,,,253.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.42,,,fee schedule,,,246.21,,,fee schedule,,,261.47,,,fee schedule,,,246.21,,,fee schedule,,,246.21,,,fee schedule,,,250.21,,,fee schedule,,,,,,,,,250.21,,,fee schedule,,,,,,,,
THER/PRO/DX IV INF INIT =<1 HR,2800000123,CDM,260,RC,96365,CPT,111,EAPG,,,,outpatient,facility,,,596.44,596.44,248.41,364.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.17,,,fee schedule,,,248.41,,,fee schedule,,,323.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,248.41,,,fee schedule,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THER/PROPH/DIAG IV INF ADDON,2800000124,CDM,260,RC,96366,CPT,,,,,,inpatient,facility,,,127.18,127.18,10.17,127.18,,,,,,,,,,,,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.46,,,percent of total billed charges,,,,,,,,,127.18,,,percent of total billed charges,,,70.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,127.18,,,percent of total billed charges,,,66.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.17,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.31,,,percent of total billed charges,,
THER/PROPH/DIAG IV INF ADDON,2800000124,CDM,260,RC,96366,CPT,,,,,,outpatient,facility,,,127.18,127.18,10.17,618.77,,74.27,,,percent of total billed charges,,,,,,,,,127.18,,,percent of total billed charges,,,61.82,,,fee schedule,,,68.79,,,fee schedule,,,,,,,,,68.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,114.46,,,percent of total billed charges,,,,,,,,,127.18,,,percent of total billed charges,,,86.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.67,,,percent of total billed charges,,,,,,,,,,,,,,,90.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",95.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.31,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.66,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,65.87,,,percent of total billed charges,,,,,,,,,,,,,,,25.44,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,116.33,,,fee schedule,,,51.87,,,fee schedule,,,,,,,,,,,,,,,10.17,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,127.18,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,,,,,,,54.79,,,fee schedule,,,114.34,,,fee schedule,,,,,,,,,,,,,,,100.55,,,fee schedule,,,127.18,,,fee schedule,,,74.32,,,fee schedule,,,95.39,,,percent of total billed charges,,,127.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,127.18,,,percent of total billed charges,,,127.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,89.31,,,percent of total billed charges,,
THER/PROPH/DIAG IV INF ADDON,2800000124,CDM,260,RC,96366,CPT,5691,APC,,,,outpatient,facility,,,127.18,127.18,52.02,78.17,,,,,,,,55.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.45,,,fee schedule,,,,,,,,,53.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,53.91,,,fee schedule,,,,,,,,,,,,,,,56.6,,,fee schedule,,,56.61,,,fee schedule,,,,,,,,,53.91,,,fee schedule,,,53.91,,,fee schedule,,,56.61,,,fee schedule,,,,,,,,,,,,,,,78.17,,,fee schedule,,,,,,,,,,,,,,,55.52,,,fee schedule,,,,,,,,,,,,,,,52.02,,,fee schedule,,,57.68,,,fee schedule,,,57.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.91,,,fee schedule,,,53.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,56.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,67.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.91,,,fee schedule,,,53.91,,,fee schedule,,,,,,,,,,,,,,,53.91,,,fee schedule,,,,,,,,,,,,,,,53.91,,,fee schedule,,,55.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.58,,,fee schedule,,,53.91,,,fee schedule,,,57.26,,,fee schedule,,,53.91,,,fee schedule,,,53.91,,,fee schedule,,,54.79,,,fee schedule,,,,,,,,,54.79,,,fee schedule,,,,,,,,
THER/PROPH/DIAG IV INF ADDON,2800000124,CDM,260,RC,96366,CPT,110,EAPG,,,,outpatient,facility,,,127.18,127.18,551.75,808.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,808.87,,,fee schedule,,,551.75,,,fee schedule,,,719.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.75,,,fee schedule,,,551.75,,,fee schedule,,,551.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TX/PROPH/DG ADDL SEQ IV INF,2800000125,CDM,260,RC,96367,CPT,,,,,,inpatient,facility,,,189.15,189.15,15.13,189.15,,,,,,,,,,,,,,189.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.24,,,percent of total billed charges,,,,,,,,,189.15,,,percent of total billed charges,,,104.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.15,,,percent of total billed charges,,,,,,,,,,,,,,,189.15,,,percent of total billed charges,,,98.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.13,,,percent of total billed charges,,,189.15,,,percent of total billed charges,,,189.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,189.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.82,,,percent of total billed charges,,
TX/PROPH/DG ADDL SEQ IV INF,2800000125,CDM,260,RC,96367,CPT,,,,,,outpatient,facility,,,189.15,189.15,15.13,618.77,,110.46,,,percent of total billed charges,,,,,,,,,189.15,,,percent of total billed charges,,,97.51,,,fee schedule,,,108.51,,,fee schedule,,,,,,,,,108.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,189.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,170.24,,,percent of total billed charges,,,,,,,,,189.15,,,percent of total billed charges,,,128.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.27,,,percent of total billed charges,,,,,,,,,,,,,,,123.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",130.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,189.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.62,,,percent of total billed charges,,,189.15,,,percent of total billed charges,,,189.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.75,,,percent of total billed charges,,,71.65,,,percent of total billed charges,,,97.96,,,percent of total billed charges,,,,,,,,,,,,,,,37.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,181.39,,,fee schedule,,,80.87,,,fee schedule,,,,,,,,,,,,,,,15.13,,,percent of total billed charges,,,189.15,,,percent of total billed charges,,,189.15,,,percent of total billed charges,,,,,,,,,,,,,,,189.15,,,percent of total billed charges,,,189.15,,,percent of total billed charges,,,,,,,,,84.52,,,fee schedule,,,178.29,,,fee schedule,,,,,,,,,,,,,,,156.78,,,fee schedule,,,189.15,,,fee schedule,,,115.89,,,fee schedule,,,141.86,,,percent of total billed charges,,,189.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,189.15,,,percent of total billed charges,,,189.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,132.82,,,percent of total billed charges,,
TX/PROPH/DG ADDL SEQ IV INF,2800000125,CDM,260,RC,96367,CPT,5692,APC,,,,outpatient,facility,,,189.15,189.15,80.26,120.6,,,,,,,,85.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,fee schedule,,,,,,,,,83.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,87.31,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,,,,,,,120.6,,,fee schedule,,,,,,,,,,,,,,,85.66,,,fee schedule,,,,,,,,,,,,,,,80.26,,,fee schedule,,,88.99,,,fee schedule,,,88.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,87.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,85.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.82,,,fee schedule,,,83.17,,,fee schedule,,,88.32,,,fee schedule,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,84.52,,,fee schedule,,,,,,,,,84.52,,,fee schedule,,,,,,,,
TX/PROPH/DG ADDL SEQ IV INF,2800000125,CDM,260,RC,96367,CPT,111,EAPG,,,,outpatient,facility,,,189.15,189.15,248.41,364.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.17,,,fee schedule,,,248.41,,,fee schedule,,,323.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,248.41,,,fee schedule,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THER/PROPH/DIAG INJ SC/IM,2800000130,CDM,260,RC,96372,CPT,,,,,,inpatient,facility,,,198.61,198.61,15.89,198.61,,,,,,,,,,,,,,198.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.75,,,percent of total billed charges,,,,,,,,,198.61,,,percent of total billed charges,,,109.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.61,,,percent of total billed charges,,,,,,,,,,,,,,,198.61,,,percent of total billed charges,,,103.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.89,,,percent of total billed charges,,,198.61,,,percent of total billed charges,,,198.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,198.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.46,,,percent of total billed charges,,
THER/PROPH/DIAG INJ SC/IM,2800000130,CDM,260,RC,96372,CPT,,,,,,outpatient,facility,,,198.61,198.61,15.89,618.77,,115.99,,,percent of total billed charges,,,,,,,,,198.61,,,percent of total billed charges,,,97.51,,,fee schedule,,,108.51,,,fee schedule,,,,,,,,,108.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,198.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,178.75,,,percent of total billed charges,,,,,,,,,198.61,,,percent of total billed charges,,,134.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.53,,,percent of total billed charges,,,,,,,,,,,,,,,123.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",130.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,198.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.56,,,percent of total billed charges,,,198.61,,,percent of total billed charges,,,198.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.94,,,percent of total billed charges,,,75.23,,,percent of total billed charges,,,102.86,,,percent of total billed charges,,,,,,,,,,,,,,,39.72,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,181.39,,,fee schedule,,,80.87,,,fee schedule,,,,,,,,,,,,,,,15.89,,,percent of total billed charges,,,198.61,,,percent of total billed charges,,,198.61,,,percent of total billed charges,,,,,,,,,,,,,,,198.61,,,percent of total billed charges,,,198.61,,,percent of total billed charges,,,,,,,,,84.52,,,fee schedule,,,178.29,,,fee schedule,,,,,,,,,,,,,,,156.78,,,fee schedule,,,198.61,,,fee schedule,,,115.89,,,fee schedule,,,63.4,,,fee schedule,,,198.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,198.61,,,percent of total billed charges,,,198.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,139.46,,,percent of total billed charges,,
THER/PROPH/DIAG INJ SC/IM,2800000130,CDM,260,RC,96372,CPT,5692,APC,,,,outpatient,facility,,,198.61,198.61,80.26,120.6,,,,,,,,85.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,fee schedule,,,,,,,,,83.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,87.31,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,,,,,,,120.6,,,fee schedule,,,,,,,,,,,,,,,85.66,,,fee schedule,,,,,,,,,,,,,,,80.26,,,fee schedule,,,88.99,,,fee schedule,,,88.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,87.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,85.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.82,,,fee schedule,,,83.17,,,fee schedule,,,88.32,,,fee schedule,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,84.52,,,fee schedule,,,,,,,,,84.52,,,fee schedule,,,,,,,,
THER/PROPH/DIAG INJ SC/IM,2800000130,CDM,260,RC,96372,CPT,109,EAPG,,,,outpatient,facility,,,198.61,198.61,66.06,96.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.84,,,fee schedule,,,66.06,,,fee schedule,,,86.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,66.06,,,fee schedule,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THER/PROPH/DIAG INJ IV PUSH,2800000131,CDM,260,RC,96374,CPT,,,,,,inpatient,facility,,,464.22,464.22,37.14,464.22,,,,,,,,,,,,,,464.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,417.8,,,percent of total billed charges,,,,,,,,,464.22,,,percent of total billed charges,,,256.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,423.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.22,,,percent of total billed charges,,,,,,,,,,,,,,,464.22,,,percent of total billed charges,,,242.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.14,,,percent of total billed charges,,,464.22,,,percent of total billed charges,,,464.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,464.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.98,,,percent of total billed charges,,
THER/PROPH/DIAG INJ IV PUSH,2800000131,CDM,260,RC,96374,CPT,,,,,,outpatient,facility,,,464.22,464.22,37.14,618.77,,271.1,,,percent of total billed charges,,,,,,,,,464.22,,,percent of total billed charges,,,305.45,,,fee schedule,,,339.91,,,fee schedule,,,,,,,,,339.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,464.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,417.8,,,percent of total billed charges,,,,,,,,,464.22,,,percent of total billed charges,,,314.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,356.52,,,percent of total billed charges,,,,,,,,,,,,,,,269.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",285.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,464.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,242.04,,,percent of total billed charges,,,464.22,,,percent of total billed charges,,,464.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.81,,,percent of total billed charges,,,175.85,,,percent of total billed charges,,,240.42,,,percent of total billed charges,,,,,,,,,,,,,,,92.84,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,464.22,,,fee schedule,,,246.14,,,fee schedule,,,,,,,,,,,,,,,37.14,,,percent of total billed charges,,,464.22,,,percent of total billed charges,,,464.22,,,percent of total billed charges,,,,,,,,,,,,,,,464.22,,,percent of total billed charges,,,464.22,,,percent of total billed charges,,,,,,,,,250.21,,,fee schedule,,,464.22,,,fee schedule,,,,,,,,,,,,,,,464.22,,,fee schedule,,,464.22,,,fee schedule,,,352.69,,,fee schedule,,,92.41,,,fee schedule,,,464.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,464.22,,,percent of total billed charges,,,464.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.11,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,325.98,,,percent of total billed charges,,
THER/PROPH/DIAG INJ IV PUSH,2800000131,CDM,260,RC,96374,CPT,5693,APC,,,,outpatient,facility,,,464.22,464.22,237.59,357,,,,,,,,253.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,246.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.67,,,fee schedule,,,,,,,,,246.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,246.21,,,fee schedule,,,,,,,,,,,,,,,258.47,,,fee schedule,,,258.52,,,fee schedule,,,,,,,,,246.21,,,fee schedule,,,246.21,,,fee schedule,,,258.52,,,fee schedule,,,,,,,,,,,,,,,357,,,fee schedule,,,,,,,,,,,,,,,253.57,,,fee schedule,,,,,,,,,,,,,,,237.59,,,fee schedule,,,263.44,,,fee schedule,,,262.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.21,,,fee schedule,,,246.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,260.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,307.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,246.21,,,fee schedule,,,246.21,,,fee schedule,,,,,,,,,,,,,,,246.21,,,fee schedule,,,,,,,,,,,,,,,246.21,,,fee schedule,,,253.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.42,,,fee schedule,,,246.21,,,fee schedule,,,261.47,,,fee schedule,,,246.21,,,fee schedule,,,246.21,,,fee schedule,,,250.21,,,fee schedule,,,,,,,,,250.21,,,fee schedule,,,,,,,,
THER/PROPH/DIAG INJ IV PUSH,2800000131,CDM,260,RC,96374,CPT,109,EAPG,,,,outpatient,facility,,,464.22,464.22,66.06,96.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.84,,,fee schedule,,,66.06,,,fee schedule,,,86.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,66.06,,,fee schedule,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TX/PRO/DX INJ NEW DRUG ADDON,2800000132,CDM,260,RC,96375,CPT,,,,,,inpatient,facility,,,139.14,139.14,11.13,139.14,,,,,,,,,,,,,,139.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.23,,,percent of total billed charges,,,,,,,,,139.14,,,percent of total billed charges,,,77.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.14,,,percent of total billed charges,,,,,,,,,,,,,,,139.14,,,percent of total billed charges,,,72.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.13,,,percent of total billed charges,,,139.14,,,percent of total billed charges,,,139.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,139.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.7,,,percent of total billed charges,,
TX/PRO/DX INJ NEW DRUG ADDON,2800000132,CDM,260,RC,96375,CPT,,,,,,outpatient,facility,,,139.14,139.14,11.13,618.77,,81.26,,,percent of total billed charges,,,,,,,,,139.14,,,percent of total billed charges,,,61.82,,,fee schedule,,,68.79,,,fee schedule,,,,,,,,,68.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,139.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,125.23,,,percent of total billed charges,,,,,,,,,139.14,,,percent of total billed charges,,,94.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.86,,,percent of total billed charges,,,,,,,,,,,,,,,123.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",130.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,139.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.55,,,percent of total billed charges,,,139.14,,,percent of total billed charges,,,139.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.75,,,percent of total billed charges,,,52.71,,,percent of total billed charges,,,72.06,,,percent of total billed charges,,,,,,,,,,,,,,,27.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,116.33,,,fee schedule,,,51.87,,,fee schedule,,,,,,,,,,,,,,,11.13,,,percent of total billed charges,,,139.14,,,percent of total billed charges,,,139.14,,,percent of total billed charges,,,,,,,,,,,,,,,139.14,,,percent of total billed charges,,,139.14,,,percent of total billed charges,,,,,,,,,54.79,,,fee schedule,,,114.34,,,fee schedule,,,,,,,,,,,,,,,100.55,,,fee schedule,,,134.06,,,fee schedule,,,74.32,,,fee schedule,,,104.35,,,percent of total billed charges,,,139.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,139.14,,,percent of total billed charges,,,139.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,97.7,,,percent of total billed charges,,
TX/PRO/DX INJ NEW DRUG ADDON,2800000132,CDM,260,RC,96375,CPT,5691,APC,,,,outpatient,facility,,,139.14,139.14,52.02,78.17,,,,,,,,55.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.45,,,fee schedule,,,,,,,,,53.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,53.91,,,fee schedule,,,,,,,,,,,,,,,56.6,,,fee schedule,,,56.61,,,fee schedule,,,,,,,,,53.91,,,fee schedule,,,53.91,,,fee schedule,,,56.61,,,fee schedule,,,,,,,,,,,,,,,78.17,,,fee schedule,,,,,,,,,,,,,,,55.52,,,fee schedule,,,,,,,,,,,,,,,52.02,,,fee schedule,,,57.68,,,fee schedule,,,57.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.91,,,fee schedule,,,53.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,56.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,67.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.91,,,fee schedule,,,53.91,,,fee schedule,,,,,,,,,,,,,,,53.91,,,fee schedule,,,,,,,,,,,,,,,53.91,,,fee schedule,,,55.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.58,,,fee schedule,,,53.91,,,fee schedule,,,57.26,,,fee schedule,,,53.91,,,fee schedule,,,53.91,,,fee schedule,,,54.79,,,fee schedule,,,,,,,,,54.79,,,fee schedule,,,,,,,,
TX/PRO/DX INJ NEW DRUG ADDON,2800000132,CDM,260,RC,96375,CPT,109,EAPG,,,,outpatient,facility,,,139.14,139.14,66.06,96.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.84,,,fee schedule,,,66.06,,,fee schedule,,,86.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,66.06,,,fee schedule,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TX/PRO/DX INJ SAME DRUG ADDON,2800000133,CDM,260,RC,96376,CPT,,,,,,inpatient,facility,,,39.08,39.08,3.13,39.08,,,,,,,,,,,,,,39.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.17,,,percent of total billed charges,,,,,,,,,39.08,,,percent of total billed charges,,,21.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.08,,,percent of total billed charges,,,,,,,,,,,,,,,39.08,,,percent of total billed charges,,,20.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,39.08,,,percent of total billed charges,,,39.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.44,,,percent of total billed charges,,
TX/PRO/DX INJ SAME DRUG ADDON,2800000133,CDM,260,RC,96376,CPT,,,,,,outpatient,facility,,,39.08,39.08,3.13,618.77,,22.82,,,percent of total billed charges,,,7.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,39.08,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,39.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,14.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,35.17,,,percent of total billed charges,,,,,,,,,39.08,,,percent of total billed charges,,,26.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,39.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.38,,,percent of total billed charges,,,39.08,,,percent of total billed charges,,,39.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,14.8,,,percent of total billed charges,,,20.24,,,percent of total billed charges,,,,,,,,,,,,,,,7.82,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,39.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,39.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.13,,,percent of total billed charges,,,39.08,,,percent of total billed charges,,,39.08,,,percent of total billed charges,,,,,,,,,,,,,,,39.08,,,percent of total billed charges,,,39.08,,,percent of total billed charges,,,,,,,,,39.08,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,29.31,,,percent of total billed charges,,,39.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,39.08,,,percent of total billed charges,,,39.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,27.44,,,percent of total billed charges,,
TX/PRO/DX INJ SAME DRUG ADDON,2800000133,CDM,260,RC,96376,CPT,999,EAPG,,,,outpatient,facility,,,39.08,39.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO ANTI-NEOPL SQ/IM,2800000135,CDM,331,RC,96401,CPT,,,,,,inpatient,facility,,,300.98,300.98,24.08,300.98,,,,,,,,,,,,,,300.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270.88,,,percent of total billed charges,,,,,,,,,300.98,,,percent of total billed charges,,,166.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,300.98,,,percent of total billed charges,,,,,,,,,,,,,,,300.98,,,percent of total billed charges,,,156.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.08,,,percent of total billed charges,,,300.98,,,percent of total billed charges,,,300.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,300.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.35,,,percent of total billed charges,,
CHEMO ANTI-NEOPL SQ/IM,2800000135,CDM,331,RC,96401,CPT,,,,,,outpatient,facility,,,300.98,300.98,24.08,618.77,,175.77,,,percent of total billed charges,,,,,,,,,300.98,,,percent of total billed charges,,,97.51,,,fee schedule,,,108.51,,,fee schedule,,,,,,,,,108.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,300.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,270.88,,,percent of total billed charges,,,,,,,,,300.98,,,percent of total billed charges,,,203.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.15,,,percent of total billed charges,,,,,,,,,,,,,,,269.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",285.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,300.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,156.93,,,percent of total billed charges,,,300.98,,,percent of total billed charges,,,300.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.74,,,percent of total billed charges,,,114.01,,,percent of total billed charges,,,155.88,,,percent of total billed charges,,,,,,,,,,,,,,,60.2,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,181.39,,,fee schedule,,,80.87,,,fee schedule,,,,,,,,,,,,,,,24.08,,,percent of total billed charges,,,300.98,,,percent of total billed charges,,,300.98,,,percent of total billed charges,,,,,,,,,,,,,,,300.98,,,percent of total billed charges,,,300.98,,,percent of total billed charges,,,,,,,,,84.52,,,fee schedule,,,178.29,,,fee schedule,,,,,,,,,,,,,,,156.78,,,fee schedule,,,209.04,,,fee schedule,,,115.89,,,fee schedule,,,225.74,,,percent of total billed charges,,,300.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,300.98,,,percent of total billed charges,,,300.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,76.97,,,fee schedule,,
CHEMO ANTI-NEOPL SQ/IM,2800000135,CDM,331,RC,96401,CPT,5692,APC,,,,outpatient,facility,,,300.98,300.98,80.26,120.6,,,,,,,,85.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,fee schedule,,,,,,,,,83.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,87.31,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,,,,,,,120.6,,,fee schedule,,,,,,,,,,,,,,,85.66,,,fee schedule,,,,,,,,,,,,,,,80.26,,,fee schedule,,,88.99,,,fee schedule,,,88.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,87.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,85.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.82,,,fee schedule,,,83.17,,,fee schedule,,,88.32,,,fee schedule,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,84.52,,,fee schedule,,,,,,,,,84.52,,,fee schedule,,,,,,,,
CHEMO ANTI-NEOPL SQ/IM,2800000135,CDM,331,RC,96401,CPT,109,EAPG,,,,outpatient,facility,,,300.98,300.98,66.06,96.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.84,,,fee schedule,,,66.06,,,fee schedule,,,86.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,66.06,,,fee schedule,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO HORMON ANTINEOPL SQ/IM,2800000136,CDM,331,RC,96402,CPT,,,,,,inpatient,facility,,,177.6,177.6,14.21,177.6,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.84,,,percent of total billed charges,,,,,,,,,177.6,,,percent of total billed charges,,,98.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,92.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.21,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.71,,,percent of total billed charges,,
CHEMO HORMON ANTINEOPL SQ/IM,2800000136,CDM,331,RC,96402,CPT,,,,,,outpatient,facility,,,177.6,177.6,14.21,618.77,,103.72,,,percent of total billed charges,,,,,,,,,177.6,,,percent of total billed charges,,,97.51,,,fee schedule,,,108.51,,,fee schedule,,,,,,,,,108.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,159.84,,,percent of total billed charges,,,,,,,,,177.6,,,percent of total billed charges,,,120.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.4,,,percent of total billed charges,,,,,,,,,,,,,,,123.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",130.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,92.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.98,,,percent of total billed charges,,,67.27,,,percent of total billed charges,,,91.98,,,percent of total billed charges,,,,,,,,,,,,,,,35.52,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,177.6,,,fee schedule,,,80.87,,,fee schedule,,,,,,,,,,,,,,,14.21,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,,,,,,,84.52,,,fee schedule,,,177.6,,,fee schedule,,,,,,,,,,,,,,,156.78,,,fee schedule,,,177.6,,,fee schedule,,,115.89,,,fee schedule,,,133.2,,,percent of total billed charges,,,177.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,177.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,47.75,,,fee schedule,,
CHEMO HORMON ANTINEOPL SQ/IM,2800000136,CDM,331,RC,96402,CPT,5692,APC,,,,outpatient,facility,,,177.6,177.6,80.26,120.6,,,,,,,,85.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,fee schedule,,,,,,,,,83.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,87.31,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,,,,,,,120.6,,,fee schedule,,,,,,,,,,,,,,,85.66,,,fee schedule,,,,,,,,,,,,,,,80.26,,,fee schedule,,,88.99,,,fee schedule,,,88.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,87.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,85.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.82,,,fee schedule,,,83.17,,,fee schedule,,,88.32,,,fee schedule,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,84.52,,,fee schedule,,,,,,,,,84.52,,,fee schedule,,,,,,,,
CHEMO HORMON ANTINEOPL SQ/IM,2800000136,CDM,331,RC,96402,CPT,109,EAPG,,,,outpatient,facility,,,177.6,177.6,66.06,96.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.84,,,fee schedule,,,66.06,,,fee schedule,,,86.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,66.06,,,fee schedule,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO IV PUSH SNGL DRUG,2800000137,CDM,331,RC,96409,CPT,,,,,,inpatient,facility,,,568.03,568.03,45.44,568.03,,,,,,,,,,,,,,568.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.23,,,percent of total billed charges,,,,,,,,,568.03,,,percent of total billed charges,,,314.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,518.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,568.03,,,percent of total billed charges,,,,,,,,,,,,,,,568.03,,,percent of total billed charges,,,296.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,568.03,,,percent of total billed charges,,,568.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,568.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.87,,,percent of total billed charges,,
CHEMO IV PUSH SNGL DRUG,2800000137,CDM,331,RC,96409,CPT,,,,,,outpatient,facility,,,568.03,568.03,45.44,618.77,,331.73,,,percent of total billed charges,,,,,,,,,568.03,,,percent of total billed charges,,,305.45,,,fee schedule,,,339.91,,,fee schedule,,,,,,,,,339.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,568.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,511.23,,,percent of total billed charges,,,,,,,,,568.03,,,percent of total billed charges,,,384.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,436.25,,,percent of total billed charges,,,,,,,,,,,,,,,505.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",535.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,568.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,296.17,,,percent of total billed charges,,,568.03,,,percent of total billed charges,,,568.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.7,,,percent of total billed charges,,,215.17,,,percent of total billed charges,,,294.18,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,567.42,,,fee schedule,,,252.99,,,fee schedule,,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,568.03,,,percent of total billed charges,,,568.03,,,percent of total billed charges,,,,,,,,,,,,,,,568.03,,,percent of total billed charges,,,568.03,,,percent of total billed charges,,,,,,,,,393.9,,,fee schedule,,,557.7,,,fee schedule,,,,,,,,,,,,,,,490.43,,,fee schedule,,,568.03,,,fee schedule,,,362.51,,,fee schedule,,,426.02,,,percent of total billed charges,,,568.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,568.03,,,percent of total billed charges,,,568.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,141.63,,,fee schedule,,
CHEMO IV PUSH SNGL DRUG,2800000137,CDM,331,RC,96409,CPT,5694,APC,,,,outpatient,facility,,,568.03,568.03,374.03,562.02,,,,,,,,399.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,387.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.48,,,fee schedule,,,,,,,,,387.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,387.6,,,fee schedule,,,,,,,,,,,,,,,406.89,,,fee schedule,,,406.98,,,fee schedule,,,,,,,,,387.6,,,fee schedule,,,387.6,,,fee schedule,,,406.98,,,fee schedule,,,,,,,,,,,,,,,562.02,,,fee schedule,,,,,,,,,,,,,,,399.18,,,fee schedule,,,,,,,,,,,,,,,374.03,,,fee schedule,,,414.73,,,fee schedule,,,413.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,387.6,,,fee schedule,,,387.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,409.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,484.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,484.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,387.6,,,fee schedule,,,387.6,,,fee schedule,,,,,,,,,,,,,,,387.6,,,fee schedule,,,,,,,,,,,,,,,387.6,,,fee schedule,,,399.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.23,,,fee schedule,,,387.6,,,fee schedule,,,411.63,,,fee schedule,,,387.6,,,fee schedule,,,387.6,,,fee schedule,,,393.9,,,fee schedule,,,,,,,,,393.9,,,fee schedule,,,,,,,,
CHEMO IV PUSH SNGL DRUG,2800000137,CDM,331,RC,96409,CPT,109,EAPG,,,,outpatient,facility,,,568.03,568.03,66.06,96.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.84,,,fee schedule,,,66.06,,,fee schedule,,,86.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,66.06,,,fee schedule,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO IV PUSH ADDL DRUG,2800000138,CDM,331,RC,96411,CPT,,,,,,inpatient,facility,,,179.23,179.23,14.34,179.23,,,,,,,,,,,,,,179.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.31,,,percent of total billed charges,,,,,,,,,179.23,,,percent of total billed charges,,,99.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.23,,,percent of total billed charges,,,,,,,,,,,,,,,179.23,,,percent of total billed charges,,,93.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.34,,,percent of total billed charges,,,179.23,,,percent of total billed charges,,,179.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,179.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.86,,,percent of total billed charges,,
CHEMO IV PUSH ADDL DRUG,2800000138,CDM,331,RC,96411,CPT,,,,,,outpatient,facility,,,179.23,179.23,14.34,618.77,,104.67,,,percent of total billed charges,,,,,,,,,179.23,,,percent of total billed charges,,,97.51,,,fee schedule,,,108.51,,,fee schedule,,,,,,,,,108.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,179.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,161.31,,,percent of total billed charges,,,,,,,,,179.23,,,percent of total billed charges,,,121.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.65,,,percent of total billed charges,,,,,,,,,,,,,,,269.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",285.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,179.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93.45,,,percent of total billed charges,,,179.23,,,percent of total billed charges,,,179.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.21,,,percent of total billed charges,,,67.89,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,,,,,,,,,,,,,35.85,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,179.23,,,fee schedule,,,80.87,,,fee schedule,,,,,,,,,,,,,,,14.34,,,percent of total billed charges,,,179.23,,,percent of total billed charges,,,179.23,,,percent of total billed charges,,,,,,,,,,,,,,,179.23,,,percent of total billed charges,,,179.23,,,percent of total billed charges,,,,,,,,,84.52,,,fee schedule,,,178.29,,,fee schedule,,,,,,,,,,,,,,,156.78,,,fee schedule,,,179.23,,,fee schedule,,,115.89,,,fee schedule,,,134.42,,,percent of total billed charges,,,179.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,179.23,,,percent of total billed charges,,,179.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,79.97,,,fee schedule,,
CHEMO IV PUSH ADDL DRUG,2800000138,CDM,331,RC,96411,CPT,5692,APC,,,,outpatient,facility,,,179.23,179.23,80.26,120.6,,,,,,,,85.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,fee schedule,,,,,,,,,83.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,87.31,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,,,,,,,120.6,,,fee schedule,,,,,,,,,,,,,,,85.66,,,fee schedule,,,,,,,,,,,,,,,80.26,,,fee schedule,,,88.99,,,fee schedule,,,88.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,87.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,85.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.82,,,fee schedule,,,83.17,,,fee schedule,,,88.32,,,fee schedule,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,84.52,,,fee schedule,,,,,,,,,84.52,,,fee schedule,,,,,,,,
CHEMO IV PUSH ADDL DRUG,2800000138,CDM,331,RC,96411,CPT,109,EAPG,,,,outpatient,facility,,,179.23,179.23,66.06,96.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.84,,,fee schedule,,,66.06,,,fee schedule,,,86.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,66.06,,,fee schedule,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,66.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO IV INFUSION 1 HR,2800000139,CDM,335,RC,96413,CPT,,,,,,inpatient,facility,,,880.12,880.12,70.41,880.12,,,,,,,,,,,,,,880.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,792.11,,,percent of total billed charges,,,,,,,,,880.12,,,percent of total billed charges,,,487.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,803.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,880.12,,,percent of total billed charges,,,,,,,,,,,,,,,880.12,,,percent of total billed charges,,,458.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.41,,,percent of total billed charges,,,880.12,,,percent of total billed charges,,,880.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,880.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,618.02,,,percent of total billed charges,,
CHEMO IV INFUSION 1 HR,2800000139,CDM,335,RC,96413,CPT,,,,,,outpatient,facility,,,880.12,880.12,70.41,880.12,,513.99,,,percent of total billed charges,,,,,,,,,880.12,,,percent of total billed charges,,,470.6,,,fee schedule,,,523.69,,,fee schedule,,,,,,,,,523.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,880.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,792.11,,,percent of total billed charges,,,,,,,,,880.12,,,percent of total billed charges,,,596.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,675.93,,,percent of total billed charges,,,,,,,,,,,,,,,818.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",866.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,880.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,458.89,,,percent of total billed charges,,,880.12,,,percent of total billed charges,,,880.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.89,,,percent of total billed charges,,,333.39,,,percent of total billed charges,,,455.81,,,percent of total billed charges,,,,,,,,,,,,,,,176.02,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,880.12,,,fee schedule,,,407.17,,,fee schedule,,,,,,,,,,,,,,,70.41,,,percent of total billed charges,,,880.12,,,percent of total billed charges,,,880.12,,,percent of total billed charges,,,,,,,,,,,,,,,880.12,,,percent of total billed charges,,,880.12,,,percent of total billed charges,,,,,,,,,393.9,,,fee schedule,,,880.12,,,fee schedule,,,,,,,,,,,,,,,789.32,,,fee schedule,,,880.12,,,fee schedule,,,583.43,,,fee schedule,,,660.09,,,percent of total billed charges,,,880.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,880.12,,,percent of total billed charges,,,880.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,440.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,191.93,,,fee schedule,,
CHEMO IV INFUSION 1 HR,2800000139,CDM,335,RC,96413,CPT,5694,APC,,,,outpatient,facility,,,880.12,880.12,374.03,562.02,,,,,,,,399.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,387.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.48,,,fee schedule,,,,,,,,,387.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,387.6,,,fee schedule,,,,,,,,,,,,,,,406.89,,,fee schedule,,,406.98,,,fee schedule,,,,,,,,,387.6,,,fee schedule,,,387.6,,,fee schedule,,,406.98,,,fee schedule,,,,,,,,,,,,,,,562.02,,,fee schedule,,,,,,,,,,,,,,,399.18,,,fee schedule,,,,,,,,,,,,,,,374.03,,,fee schedule,,,414.73,,,fee schedule,,,413.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,387.6,,,fee schedule,,,387.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,409.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,484.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,484.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,387.6,,,fee schedule,,,387.6,,,fee schedule,,,,,,,,,,,,,,,387.6,,,fee schedule,,,,,,,,,,,,,,,387.6,,,fee schedule,,,399.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.23,,,fee schedule,,,387.6,,,fee schedule,,,411.63,,,fee schedule,,,387.6,,,fee schedule,,,387.6,,,fee schedule,,,393.9,,,fee schedule,,,,,,,,,393.9,,,fee schedule,,,,,,,,
CHEMO IV INFUSION 1 HR,2800000139,CDM,335,RC,96413,CPT,111,EAPG,,,,outpatient,facility,,,880.12,880.12,248.41,364.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.17,,,fee schedule,,,248.41,,,fee schedule,,,323.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,248.41,,,fee schedule,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO IV INFUSION ADDL HR,2800000140,CDM,335,RC,96415,CPT,,,,,,inpatient,facility,,,177.6,177.6,14.21,177.6,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.84,,,percent of total billed charges,,,,,,,,,177.6,,,percent of total billed charges,,,98.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,92.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.21,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.71,,,percent of total billed charges,,
CHEMO IV INFUSION ADDL HR,2800000140,CDM,335,RC,96415,CPT,,,,,,outpatient,facility,,,177.6,177.6,14.21,618.77,,103.72,,,percent of total billed charges,,,,,,,,,177.6,,,percent of total billed charges,,,97.51,,,fee schedule,,,108.51,,,fee schedule,,,,,,,,,108.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,159.84,,,percent of total billed charges,,,,,,,,,177.6,,,percent of total billed charges,,,120.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.4,,,percent of total billed charges,,,,,,,,,,,,,,,123.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",130.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,92.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.98,,,percent of total billed charges,,,67.27,,,percent of total billed charges,,,91.98,,,percent of total billed charges,,,,,,,,,,,,,,,35.52,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,177.6,,,fee schedule,,,80.87,,,fee schedule,,,,,,,,,,,,,,,14.21,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,,,,,,,84.52,,,fee schedule,,,177.6,,,fee schedule,,,,,,,,,,,,,,,156.78,,,fee schedule,,,177.6,,,fee schedule,,,115.89,,,fee schedule,,,133.2,,,percent of total billed charges,,,177.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,177.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,41.27,,,fee schedule,,
CHEMO IV INFUSION ADDL HR,2800000140,CDM,335,RC,96415,CPT,5692,APC,,,,outpatient,facility,,,177.6,177.6,80.26,120.6,,,,,,,,85.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,fee schedule,,,,,,,,,83.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,87.31,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,,,,,,,120.6,,,fee schedule,,,,,,,,,,,,,,,85.66,,,fee schedule,,,,,,,,,,,,,,,80.26,,,fee schedule,,,88.99,,,fee schedule,,,88.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,87.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,85.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.82,,,fee schedule,,,83.17,,,fee schedule,,,88.32,,,fee schedule,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,84.52,,,fee schedule,,,,,,,,,84.52,,,fee schedule,,,,,,,,
CHEMO IV INFUSION ADDL HR,2800000140,CDM,335,RC,96415,CPT,110,EAPG,,,,outpatient,facility,,,177.6,177.6,551.75,808.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,808.87,,,fee schedule,,,551.75,,,fee schedule,,,719.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.75,,,fee schedule,,,551.75,,,fee schedule,,,551.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO IV INFUS EA ADL SEQ=<1HR,2800000142,CDM,335,RC,96417,CPT,,,,,,inpatient,facility,,,177.6,177.6,14.21,177.6,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.84,,,percent of total billed charges,,,,,,,,,177.6,,,percent of total billed charges,,,98.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,92.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.21,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.71,,,percent of total billed charges,,
CHEMO IV INFUS EA ADL SEQ=<1HR,2800000142,CDM,335,RC,96417,CPT,,,,,,outpatient,facility,,,177.6,177.6,14.21,618.77,,103.72,,,percent of total billed charges,,,,,,,,,177.6,,,percent of total billed charges,,,97.51,,,fee schedule,,,108.51,,,fee schedule,,,,,,,,,108.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,159.84,,,percent of total billed charges,,,,,,,,,177.6,,,percent of total billed charges,,,120.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.4,,,percent of total billed charges,,,,,,,,,,,,,,,123.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",130.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,92.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.98,,,percent of total billed charges,,,67.27,,,percent of total billed charges,,,91.98,,,percent of total billed charges,,,,,,,,,,,,,,,35.52,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,177.6,,,fee schedule,,,80.87,,,fee schedule,,,,,,,,,,,,,,,14.21,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,177.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,,,,,,,84.52,,,fee schedule,,,177.6,,,fee schedule,,,,,,,,,,,,,,,156.78,,,fee schedule,,,177.6,,,fee schedule,,,115.89,,,fee schedule,,,133.2,,,percent of total billed charges,,,177.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,177.6,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,93.96,,,fee schedule,,
CHEMO IV INFUS EA ADL SEQ=<1HR,2800000142,CDM,335,RC,96417,CPT,5692,APC,,,,outpatient,facility,,,177.6,177.6,80.26,120.6,,,,,,,,85.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,fee schedule,,,,,,,,,83.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,87.31,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,87.33,,,fee schedule,,,,,,,,,,,,,,,120.6,,,fee schedule,,,,,,,,,,,,,,,85.66,,,fee schedule,,,,,,,,,,,,,,,80.26,,,fee schedule,,,88.99,,,fee schedule,,,88.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,87.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,,,,,,,,,,,,,83.17,,,fee schedule,,,85.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.82,,,fee schedule,,,83.17,,,fee schedule,,,88.32,,,fee schedule,,,83.17,,,fee schedule,,,83.17,,,fee schedule,,,84.52,,,fee schedule,,,,,,,,,84.52,,,fee schedule,,,,,,,,
CHEMO IV INFUS EA ADL SEQ=<1HR,2800000142,CDM,335,RC,96417,CPT,111,EAPG,,,,outpatient,facility,,,177.6,177.6,248.41,364.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.17,,,fee schedule,,,248.41,,,fee schedule,,,323.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,248.41,,,fee schedule,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,248.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEW PT LEVEL 2,2800000155,CDM,510,RC,99202,CPT,,,,,,inpatient,facility,,,122.73,122.73,9.82,122.73,,,,,,,,,,,,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.46,,,percent of total billed charges,,,,,,,,,122.73,,,percent of total billed charges,,,67.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,122.73,,,percent of total billed charges,,,63.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.18,,,percent of total billed charges,,
NEW PT LEVEL 2,2800000155,CDM,510,RC,99202,CPT,,,,,,outpatient,facility,,,122.73,122.73,9.82,618.77,,,,,,,service not payable,23.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,122.73,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,44.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,110.46,,,percent of total billed charges,,,,,,,,,122.73,,,percent of total billed charges,,,83.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,246,,,fee schedule,,,,,,,,,94.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.99,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.27,,,percent of total billed charges,,,46.49,,,percent of total billed charges,,,63.56,,,percent of total billed charges,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,51.36,,,fee schedule,,,22.9,,,fee schedule,,,122.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,122.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.82,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,122.73,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,,,,,,,122.73,,,fee schedule,,,32.55,,,fee schedule,,,,,,,,,,,,,,,24.41,,,fee schedule,,,32.55,,,fee schedule,,,21.16,,,fee schedule,,,,,,,,service not payable,122.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,122.73,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.37,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,68.83,,,fee schedule,,
NEW PT LEVEL 2,2800000155,CDM,510,RC,99202,CPT,852,EAPG,,,,outpatient,facility,,,122.73,122.73,205.63,301.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.45,,,fee schedule,,,205.63,,,fee schedule,,,268,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEW PT LEVEL 2,2800000155,CDM,510,RC,G0463,HCPCS,,,,,,inpatient,facility,,,122.73,122.73,9.82,122.73,,,,,,,,,,,,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.46,,,percent of total billed charges,,,,,,,,,122.73,,,percent of total billed charges,,,67.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,122.73,,,percent of total billed charges,,,63.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.18,,,percent of total billed charges,,
NEW PT LEVEL 2,2800000155,CDM,510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,122.73,122.73,9.82,618.77,,,,,,,service not payable,,,,,,,122.73,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,110.46,,,percent of total billed charges,,,,,,,,,122.73,,,percent of total billed charges,,,83.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.99,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.27,,,percent of total billed charges,,,46.49,,,percent of total billed charges,,,63.56,,,percent of total billed charges,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,9.82,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,122.73,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,,,,,,,153.04,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,122.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,122.73,,,percent of total billed charges,,,122.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.37,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,86.18,,,percent of total billed charges,,
NEW PT LEVEL 2,2800000155,CDM,510,RC,G0463,HCPCS,5012,APC,,,,outpatient,facility,,,122.73,122.73,145.32,218.36,,,,,,,,155.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.1,,,fee schedule,,,,,,,,,150.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,158.09,,,fee schedule,,,158.12,,,fee schedule,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,158.12,,,fee schedule,,,,,,,,,,,,,,,218.36,,,fee schedule,,,,,,,,,,,,,,,155.09,,,fee schedule,,,,,,,,,,,,,,,145.32,,,fee schedule,,,161.13,,,fee schedule,,,160.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,159.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,188.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,150.59,,,fee schedule,,,155.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.18,,,fee schedule,,,150.59,,,fee schedule,,,159.93,,,fee schedule,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,153.04,,,fee schedule,,,,,,,,
NEW PT LEVEL 2,2800000155,CDM,510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,122.73,122.73,205.63,301.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.45,,,fee schedule,,,205.63,,,fee schedule,,,268,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEW PT LEVEL 3,2800000157,CDM,510,RC,99203,CPT,,,,,,inpatient,facility,,,205.33,205.33,16.43,205.33,,,,,,,,,,,,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,,,,205.33,,,percent of total billed charges,,,113.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,205.33,,,percent of total billed charges,,,107.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.18,,,percent of total billed charges,,
NEW PT LEVEL 3,2800000157,CDM,510,RC,99203,CPT,,,,,,outpatient,facility,,,205.33,205.33,16.43,618.77,,,,,,,service not payable,40.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,205.33,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,75.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,184.8,,,percent of total billed charges,,,,,,,,,205.33,,,percent of total billed charges,,,139.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,246,,,fee schedule,,,,,,,,,157.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,107.06,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,77.78,,,percent of total billed charges,,,106.34,,,percent of total billed charges,,,,,,,,,,,,,,,41.07,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,51.36,,,fee schedule,,,22.9,,,fee schedule,,,205.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,205.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.43,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,205.33,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,,,,,,,205.33,,,fee schedule,,,32.55,,,fee schedule,,,,,,,,,,,,,,,24.41,,,fee schedule,,,32.55,,,fee schedule,,,21.16,,,fee schedule,,,,,,,,service not payable,205.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,205.33,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.67,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,100,,,fee schedule,,
NEW PT LEVEL 3,2800000157,CDM,510,RC,99203,CPT,852,EAPG,,,,outpatient,facility,,,205.33,205.33,205.63,301.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.45,,,fee schedule,,,205.63,,,fee schedule,,,268,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEW PT LEVEL 3,2800000157,CDM,510,RC,G0463,HCPCS,,,,,,inpatient,facility,,,205.33,205.33,16.43,205.33,,,,,,,,,,,,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,,,,205.33,,,percent of total billed charges,,,113.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,205.33,,,percent of total billed charges,,,107.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.18,,,percent of total billed charges,,
NEW PT LEVEL 3,2800000157,CDM,510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,205.33,205.33,16.43,618.77,,,,,,,service not payable,,,,,,,205.33,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,184.8,,,percent of total billed charges,,,,,,,,,205.33,,,percent of total billed charges,,,139.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,107.06,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,77.78,,,percent of total billed charges,,,106.34,,,percent of total billed charges,,,,,,,,,,,,,,,41.07,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,205.33,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,,,,,,,153.04,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,205.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,205.33,,,percent of total billed charges,,,205.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.67,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,144.18,,,percent of total billed charges,,
NEW PT LEVEL 3,2800000157,CDM,510,RC,G0463,HCPCS,5012,APC,,,,outpatient,facility,,,205.33,205.33,145.32,218.36,,,,,,,,155.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.1,,,fee schedule,,,,,,,,,150.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,158.09,,,fee schedule,,,158.12,,,fee schedule,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,158.12,,,fee schedule,,,,,,,,,,,,,,,218.36,,,fee schedule,,,,,,,,,,,,,,,155.09,,,fee schedule,,,,,,,,,,,,,,,145.32,,,fee schedule,,,161.13,,,fee schedule,,,160.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,159.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,188.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,150.59,,,fee schedule,,,155.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.18,,,fee schedule,,,150.59,,,fee schedule,,,159.93,,,fee schedule,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,153.04,,,fee schedule,,,,,,,,
NEW PT LEVEL 3,2800000157,CDM,510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,205.33,205.33,205.63,301.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.45,,,fee schedule,,,205.63,,,fee schedule,,,268,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EST PT LEVEL 1,2800000162,CDM,510,RC,99211,CPT,,,,,,inpatient,facility,,,101.32,101.32,8.11,101.32,,,,,,,,,,,,,,101.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.19,,,percent of total billed charges,,,,,,,,,101.32,,,percent of total billed charges,,,56.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.32,,,percent of total billed charges,,,,,,,,,,,,,,,101.32,,,percent of total billed charges,,,52.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.11,,,percent of total billed charges,,,101.32,,,percent of total billed charges,,,101.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,101.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.15,,,percent of total billed charges,,
EST PT LEVEL 1,2800000162,CDM,510,RC,99211,CPT,,,,,,outpatient,facility,,,101.32,101.32,8.11,618.77,,,,,,,service not payable,19.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,101.32,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,37.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,91.19,,,percent of total billed charges,,,,,,,,,101.32,,,percent of total billed charges,,,68.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,101.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.83,,,percent of total billed charges,,,101.32,,,percent of total billed charges,,,101.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,52.47,,,percent of total billed charges,,,,,,,,,,,,,,,20.26,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,51.36,,,fee schedule,,,22.9,,,fee schedule,,,101.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,101.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.11,,,percent of total billed charges,,,101.32,,,percent of total billed charges,,,101.32,,,percent of total billed charges,,,,,,,,,,,,,,,101.32,,,percent of total billed charges,,,101.32,,,percent of total billed charges,,,,,,,,,101.32,,,fee schedule,,,32.55,,,fee schedule,,,,,,,,,,,,,,,24.41,,,fee schedule,,,32.55,,,fee schedule,,,21.16,,,fee schedule,,,,,,,,service not payable,101.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,101.32,,,percent of total billed charges,,,101.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,22.67,,,fee schedule,,
EST PT LEVEL 1,2800000162,CDM,510,RC,99211,CPT,852,EAPG,,,,outpatient,facility,,,101.32,101.32,205.63,301.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.45,,,fee schedule,,,205.63,,,fee schedule,,,268,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EST PT LEVEL 2,2800000164,CDM,510,RC,99212,CPT,,,,,,inpatient,facility,,,67.79,67.79,5.42,67.79,,,,,,,,,,,,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.01,,,percent of total billed charges,,,,,,,,,67.79,,,percent of total billed charges,,,37.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,67.79,,,percent of total billed charges,,,35.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.42,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.6,,,percent of total billed charges,,
EST PT LEVEL 2,2800000164,CDM,510,RC,99212,CPT,,,,,,outpatient,facility,,,67.79,67.79,5.42,618.77,,,,,,,service not payable,13.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,67.79,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,24.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,61.01,,,percent of total billed charges,,,,,,,,,67.79,,,percent of total billed charges,,,45.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,fee schedule,,,,,,,,,52.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.35,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.52,,,percent of total billed charges,,,25.68,,,percent of total billed charges,,,35.11,,,percent of total billed charges,,,,,,,,,,,,,,,13.56,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,51.36,,,fee schedule,,,22.9,,,fee schedule,,,67.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,67.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.42,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,67.79,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,,,,,,,67.79,,,fee schedule,,,32.55,,,fee schedule,,,,,,,,,,,,,,,24.41,,,fee schedule,,,32.55,,,fee schedule,,,21.16,,,fee schedule,,,,,,,,service not payable,67.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,67.79,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,41.58,,,fee schedule,,
EST PT LEVEL 2,2800000164,CDM,510,RC,99212,CPT,852,EAPG,,,,outpatient,facility,,,67.79,67.79,205.63,301.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.45,,,fee schedule,,,205.63,,,fee schedule,,,268,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EST PT LEVEL 2,2800000164,CDM,510,RC,G0463,HCPCS,,,,,,inpatient,facility,,,67.79,67.79,5.42,67.79,,,,,,,,,,,,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.01,,,percent of total billed charges,,,,,,,,,67.79,,,percent of total billed charges,,,37.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,67.79,,,percent of total billed charges,,,35.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.42,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.6,,,percent of total billed charges,,
EST PT LEVEL 2,2800000164,CDM,510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,67.79,67.79,5.42,618.77,,,,,,,service not payable,,,,,,,67.79,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,61.01,,,percent of total billed charges,,,,,,,,,67.79,,,percent of total billed charges,,,45.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.35,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.52,,,percent of total billed charges,,,25.68,,,percent of total billed charges,,,35.11,,,percent of total billed charges,,,,,,,,,,,,,,,13.56,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,5.42,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,67.79,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,,,,,,,153.04,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,67.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,67.79,,,percent of total billed charges,,,67.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,47.6,,,percent of total billed charges,,
EST PT LEVEL 2,2800000164,CDM,510,RC,G0463,HCPCS,5012,APC,,,,outpatient,facility,,,67.79,67.79,145.32,218.36,,,,,,,,155.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.1,,,fee schedule,,,,,,,,,150.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,158.09,,,fee schedule,,,158.12,,,fee schedule,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,158.12,,,fee schedule,,,,,,,,,,,,,,,218.36,,,fee schedule,,,,,,,,,,,,,,,155.09,,,fee schedule,,,,,,,,,,,,,,,145.32,,,fee schedule,,,161.13,,,fee schedule,,,160.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,159.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,188.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,150.59,,,fee schedule,,,155.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.18,,,fee schedule,,,150.59,,,fee schedule,,,159.93,,,fee schedule,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,153.04,,,fee schedule,,,,,,,,
EST PT LEVEL 2,2800000164,CDM,510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,67.79,67.79,205.63,301.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.45,,,fee schedule,,,205.63,,,fee schedule,,,268,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EST PT LEVEL 3,2800000166,CDM,510,RC,99213,CPT,,,,,,inpatient,facility,,,137.99,137.99,11.04,137.99,,,,,,,,,,,,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.19,,,percent of total billed charges,,,,,,,,,137.99,,,percent of total billed charges,,,76.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,137.99,,,percent of total billed charges,,,71.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.04,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.9,,,percent of total billed charges,,
EST PT LEVEL 3,2800000166,CDM,510,RC,99213,CPT,,,,,,outpatient,facility,,,137.99,137.99,11.04,618.77,,,,,,,service not payable,26.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,137.99,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,50.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,124.19,,,percent of total billed charges,,,,,,,,,137.99,,,percent of total billed charges,,,93.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,fee schedule,,,,,,,,,105.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.95,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.87,,,percent of total billed charges,,,52.27,,,percent of total billed charges,,,71.47,,,percent of total billed charges,,,,,,,,,,,,,,,27.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,51.36,,,fee schedule,,,22.9,,,fee schedule,,,137.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,137.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.04,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,137.99,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,,,,,,,137.99,,,fee schedule,,,32.55,,,fee schedule,,,,,,,,,,,,,,,24.41,,,fee schedule,,,32.55,,,fee schedule,,,21.16,,,fee schedule,,,,,,,,service not payable,137.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,137.99,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,65.91,,,fee schedule,,
EST PT LEVEL 3,2800000166,CDM,510,RC,99213,CPT,852,EAPG,,,,outpatient,facility,,,137.99,137.99,205.63,301.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.45,,,fee schedule,,,205.63,,,fee schedule,,,268,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EST PT LEVEL 3,2800000166,CDM,510,RC,G0463,HCPCS,,,,,,inpatient,facility,,,137.99,137.99,11.04,137.99,,,,,,,,,,,,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.19,,,percent of total billed charges,,,,,,,,,137.99,,,percent of total billed charges,,,76.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,137.99,,,percent of total billed charges,,,71.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.04,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.9,,,percent of total billed charges,,
EST PT LEVEL 3,2800000166,CDM,510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,137.99,137.99,11.04,618.77,,,,,,,service not payable,,,,,,,137.99,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,124.19,,,percent of total billed charges,,,,,,,,,137.99,,,percent of total billed charges,,,93.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.95,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.87,,,percent of total billed charges,,,52.27,,,percent of total billed charges,,,71.47,,,percent of total billed charges,,,,,,,,,,,,,,,27.6,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,11.04,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,137.99,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,,,,,,,153.04,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,137.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,137.99,,,percent of total billed charges,,,137.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,96.9,,,percent of total billed charges,,
EST PT LEVEL 3,2800000166,CDM,510,RC,G0463,HCPCS,5012,APC,,,,outpatient,facility,,,137.99,137.99,145.32,218.36,,,,,,,,155.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.1,,,fee schedule,,,,,,,,,150.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,158.09,,,fee schedule,,,158.12,,,fee schedule,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,158.12,,,fee schedule,,,,,,,,,,,,,,,218.36,,,fee schedule,,,,,,,,,,,,,,,155.09,,,fee schedule,,,,,,,,,,,,,,,145.32,,,fee schedule,,,161.13,,,fee schedule,,,160.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,159.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,188.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,150.59,,,fee schedule,,,155.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.18,,,fee schedule,,,150.59,,,fee schedule,,,159.93,,,fee schedule,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,153.04,,,fee schedule,,,,,,,,
EST PT LEVEL 3,2800000166,CDM,510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,137.99,137.99,205.63,301.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.45,,,fee schedule,,,205.63,,,fee schedule,,,268,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EST PT LEVEL 4,2800000168,CDM,510,RC,99214,CPT,,,,,,inpatient,facility,,,211.95,211.95,16.96,211.95,,,,,,,,,,,,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.75,,,percent of total billed charges,,,,,,,,,211.95,,,percent of total billed charges,,,117.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,211.95,,,percent of total billed charges,,,110.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.83,,,percent of total billed charges,,
EST PT LEVEL 4,2800000168,CDM,510,RC,99214,CPT,,,,,,outpatient,facility,,,211.95,211.95,16.96,618.77,,,,,,,service not payable,41.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,211.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,77.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,190.75,,,percent of total billed charges,,,,,,,,,211.95,,,percent of total billed charges,,,143.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,fee schedule,,,,,,,,,162.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,110.51,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.08,,,percent of total billed charges,,,80.29,,,percent of total billed charges,,,109.77,,,percent of total billed charges,,,,,,,,,,,,,,,42.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,51.36,,,fee schedule,,,22.9,,,fee schedule,,,211.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,211.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.96,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,211.95,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,,,,,,,211.95,,,fee schedule,,,32.55,,,fee schedule,,,,,,,,,,,,,,,24.41,,,fee schedule,,,32.55,,,fee schedule,,,21.16,,,fee schedule,,,,,,,,service not payable,211.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,211.95,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,98.77,,,fee schedule,,
EST PT LEVEL 4,2800000168,CDM,510,RC,99214,CPT,852,EAPG,,,,outpatient,facility,,,211.95,211.95,205.63,301.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.45,,,fee schedule,,,205.63,,,fee schedule,,,268,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EST PT LEVEL 4,2800000168,CDM,510,RC,G0463,HCPCS,,,,,,inpatient,facility,,,211.95,211.95,16.96,211.95,,,,,,,,,,,,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.75,,,percent of total billed charges,,,,,,,,,211.95,,,percent of total billed charges,,,117.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,211.95,,,percent of total billed charges,,,110.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.83,,,percent of total billed charges,,
EST PT LEVEL 4,2800000168,CDM,510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,211.95,211.95,16.96,618.77,,,,,,,service not payable,,,,,,,211.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,190.75,,,percent of total billed charges,,,,,,,,,211.95,,,percent of total billed charges,,,143.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,110.51,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.08,,,percent of total billed charges,,,80.29,,,percent of total billed charges,,,109.77,,,percent of total billed charges,,,,,,,,,,,,,,,42.39,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,211.95,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,,,,,,,153.04,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,211.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,211.95,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,148.83,,,percent of total billed charges,,
EST PT LEVEL 4,2800000168,CDM,510,RC,G0463,HCPCS,5012,APC,,,,outpatient,facility,,,211.95,211.95,145.32,218.36,,,,,,,,155.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.1,,,fee schedule,,,,,,,,,150.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,158.09,,,fee schedule,,,158.12,,,fee schedule,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,158.12,,,fee schedule,,,,,,,,,,,,,,,218.36,,,fee schedule,,,,,,,,,,,,,,,155.09,,,fee schedule,,,,,,,,,,,,,,,145.32,,,fee schedule,,,161.13,,,fee schedule,,,160.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,159.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,188.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,150.59,,,fee schedule,,,155.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.18,,,fee schedule,,,150.59,,,fee schedule,,,159.93,,,fee schedule,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,153.04,,,fee schedule,,,,,,,,
EST PT LEVEL 4,2800000168,CDM,510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,211.95,211.95,205.63,301.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.45,,,fee schedule,,,205.63,,,fee schedule,,,268,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EST PT LEVEL 5,2800000170,CDM,510,RC,99215,CPT,,,,,,inpatient,facility,,,298.71,298.71,23.9,298.71,,,,,,,,,,,,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.84,,,percent of total billed charges,,,,,,,,,298.71,,,percent of total billed charges,,,165.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,298.71,,,percent of total billed charges,,,155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.9,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.75,,,percent of total billed charges,,
EST PT LEVEL 5,2800000170,CDM,510,RC,99215,CPT,,,,,,outpatient,facility,,,298.71,298.71,21.16,618.77,,,,,,,service not payable,58.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,298.71,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,109.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,268.84,,,percent of total billed charges,,,,,,,,,298.71,,,percent of total billed charges,,,202.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,fee schedule,,,,,,,,,229.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,155.75,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.02,,,percent of total billed charges,,,113.15,,,percent of total billed charges,,,154.7,,,percent of total billed charges,,,,,,,,,,,,,,,59.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,51.36,,,fee schedule,,,22.9,,,fee schedule,,,298.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,298.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.9,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,298.71,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,,,,,,,298.71,,,fee schedule,,,32.55,,,fee schedule,,,,,,,,,,,,,,,24.41,,,fee schedule,,,32.55,,,fee schedule,,,21.16,,,fee schedule,,,,,,,,service not payable,298.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,298.71,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,132.82,,,fee schedule,,
EST PT LEVEL 5,2800000170,CDM,510,RC,99215,CPT,852,EAPG,,,,outpatient,facility,,,298.71,298.71,205.63,301.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.45,,,fee schedule,,,205.63,,,fee schedule,,,268,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EST PT LEVEL 5,2800000170,CDM,510,RC,G0463,HCPCS,,,,,,inpatient,facility,,,298.71,298.71,23.9,298.71,,,,,,,,,,,,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.84,,,percent of total billed charges,,,,,,,,,298.71,,,percent of total billed charges,,,165.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,298.71,,,percent of total billed charges,,,155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.9,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.75,,,percent of total billed charges,,
EST PT LEVEL 5,2800000170,CDM,510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,298.71,298.71,23.9,618.77,,,,,,,service not payable,,,,,,,298.71,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,268.84,,,percent of total billed charges,,,,,,,,,298.71,,,percent of total billed charges,,,202.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,229.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,618.77,,,per diem,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,155.75,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.02,,,percent of total billed charges,,,113.15,,,percent of total billed charges,,,154.7,,,percent of total billed charges,,,,,,,,,,,,,,,59.74,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,23.9,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,298.71,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,,,,,,,153.04,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,298.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,298.71,,,percent of total billed charges,,,298.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,209.75,,,percent of total billed charges,,
EST PT LEVEL 5,2800000170,CDM,510,RC,G0463,HCPCS,5012,APC,,,,outpatient,facility,,,298.71,298.71,145.32,218.36,,,,,,,,155.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.1,,,fee schedule,,,,,,,,,150.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,158.09,,,fee schedule,,,158.12,,,fee schedule,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,158.12,,,fee schedule,,,,,,,,,,,,,,,218.36,,,fee schedule,,,,,,,,,,,,,,,155.09,,,fee schedule,,,,,,,,,,,,,,,145.32,,,fee schedule,,,161.13,,,fee schedule,,,160.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,159.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,188.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,,,,,,,,,,,,,150.59,,,fee schedule,,,,,,,,,,,,,,,150.59,,,fee schedule,,,155.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.18,,,fee schedule,,,150.59,,,fee schedule,,,159.93,,,fee schedule,,,150.59,,,fee schedule,,,150.59,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,153.04,,,fee schedule,,,,,,,,
EST PT LEVEL 5,2800000170,CDM,510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,298.71,298.71,205.63,301.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.45,,,fee schedule,,,205.63,,,fee schedule,,,268,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,205.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC ABDL TUM DEEP 5 CM/>,2800000192,CDM,761,RC,22901,CPT,,,,,,inpatient,facility,,,6409.39,6409.39,512.75,6409.39,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5768.45,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,3548.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5847.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,3341.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1281.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.75,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4500.67,,,percent of total billed charges,,
EXC ABDL TUM DEEP 5 CM/>,2800000192,CDM,761,RC,22901,CPT,,,,,,outpatient,facility,,,6409.39,6409.39,319.69,6930.49,,3743.08,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,3881.03,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,4318.9,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,4318.9,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5768.45,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,4340.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4922.41,,,percent of total billed charges,,,,,,,,,,,,,,,4129.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",4370.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3341.86,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4871.14,,,percent of total billed charges,,,2427.88,,,percent of total billed charges,,,3319.42,,,percent of total billed charges,,,,,,,,,,,,,,,1281.88,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6061.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",2702.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,512.75,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,3398.86,,,fee schedule,,,6930.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,5197.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",6930.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",4504.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",4807.04,,,percent of total billed charges,,,6409.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,4500.67,,,percent of total billed charges,,
EXC ABDL TUM DEEP 5 CM/>,2800000192,CDM,761,RC,22901,CPT,5073,APC,,,,outpatient,facility,,,6409.39,6409.39,3227.42,4849.5,,,,,,,,3444.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3377.92,,,fee schedule,,,,,,,,,3344.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,3511.02,,,fee schedule,,,3511.7,,,fee schedule,,,,,,,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,3511.7,,,fee schedule,,,,,,,,,,,,,,,4849.5,,,fee schedule,,,,,,,,,,,,,,,3444.41,,,fee schedule,,,,,,,,,,,,,,,3227.42,,,fee schedule,,,3578.59,,,fee schedule,,,3568.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3534.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4180.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,,,,,,,,,,,,,3344.48,,,fee schedule,,,3444.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3743.97,,,fee schedule,,,3344.48,,,fee schedule,,,3551.81,,,fee schedule,,,3344.48,,,fee schedule,,,3344.48,,,fee schedule,,,3398.86,,,fee schedule,,,,,,,,,3398.86,,,fee schedule,,,,,,,,
EXC ABDL TUM DEEP 5 CM/>,2800000192,CDM,761,RC,22901,CPT,51,EAPG,,,,outpatient,facility,,,6409.39,6409.39,1857.72,2723.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2723.42,,,fee schedule,,,1857.72,,,fee schedule,,,2421.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1857.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1857.72,,,fee schedule,,,1857.72,,,fee schedule,,,1857.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1857.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1857.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REMOVL OF BREAST LESION 1+ RT,2800000206,CDM,761,RC,19120,CPT,,,,,,inpatient,facility,,,6409.39,6409.39,512.75,6409.39,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5768.45,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,3548.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5847.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,3341.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1281.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.75,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4500.67,,,percent of total billed charges,,
REMOVL OF BREAST LESION 1+ RT,2800000206,CDM,761,RC,19120,CPT,,,,,,outpatient,facility,,,6409.39,6409.39,319.69,6930.49,,3743.08,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,4595.33,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,5113.79,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,5113.79,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,5768.45,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,4340.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4922.41,,,percent of total billed charges,,,,,,,,,,,,,,,6388.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",6760.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3341.86,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1600,,,case rate,,,2427.88,,,percent of total billed charges,,,3319.42,,,percent of total billed charges,,,,,,,,,,,,,,,1281.88,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,6061.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",2702.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,512.75,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,4547.5,,,fee schedule,,,6930.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,5197.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",6930.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",4504.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",4807.04,,,percent of total billed charges,,,6409.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,922.44,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
REMOVL OF BREAST LESION 1+ RT,2800000206,CDM,761,RC,19120,CPT,5091,APC,,,,outpatient,facility,,,6409.39,6409.39,4318.12,6488.37,,,,,,,,4608.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,4474.74,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4519.49,,,fee schedule,,,,,,,,,4474.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,4474.74,,,fee schedule,,,,,,,,,,,,,,,4697.57,,,fee schedule,,,4698.48,,,fee schedule,,,,,,,,,4474.74,,,fee schedule,,,4474.74,,,fee schedule,,,4698.48,,,fee schedule,,,,,,,,,,,,,,,6488.37,,,fee schedule,,,,,,,,,,,,,,,4608.44,,,fee schedule,,,,,,,,,,,,,,,4318.12,,,fee schedule,,,4787.97,,,fee schedule,,,4774.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4474.74,,,fee schedule,,,4474.74,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4729.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5593.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5593.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,4474.74,,,fee schedule,,,4474.74,,,fee schedule,,,,,,,,,,,,,,,4474.74,,,fee schedule,,,,,,,,,,,,,,,4474.74,,,fee schedule,,,4608.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5022.38,,,fee schedule,,,4474.74,,,fee schedule,,,4752.14,,,fee schedule,,,4474.74,,,fee schedule,,,4474.74,,,fee schedule,,,4547.5,,,fee schedule,,,,,,,,,4547.5,,,fee schedule,,,,,,,,
REMOVL OF BREAST LESION 1+ RT,2800000206,CDM,761,RC,19120,CPT,20,EAPG,,,,outpatient,facility,,,6409.39,6409.39,1484.09,2175.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2175.68,,,fee schedule,,,1484.09,,,fee schedule,,,1934.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1484.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1484.09,,,fee schedule,,,1484.09,,,fee schedule,,,1484.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1484.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1484.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARPAL TUNNEL TX INJ RT,2800000207,CDM,761,RC,20526,CPT,,,,,,inpatient,facility,,,574.72,574.72,45.98,574.72,,,,,,,,,,,,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,517.25,,,percent of total billed charges,,,,,,,,,574.72,,,percent of total billed charges,,,318.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,524.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,574.72,,,percent of total billed charges,,,299.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.98,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.57,,,percent of total billed charges,,
CARPAL TUNNEL TX INJ RT,2800000207,CDM,761,RC,20526,CPT,,,,,,outpatient,facility,,,574.72,574.72,32.73,691.42,,335.64,,,percent of total billed charges,,,,,,,,,574.72,,,percent of total billed charges,,,403.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,449.42,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,449.42,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,517.25,,,percent of total billed charges,,,,,,,,,574.72,,,percent of total billed charges,,,389.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,441.38,,,percent of total billed charges,,,,,,,,,,,,,,,653.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",691.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,299.66,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,436.79,,,percent of total billed charges,,,217.7,,,percent of total billed charges,,,297.65,,,percent of total billed charges,,,,,,,,,,,,,,,114.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,497.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",221.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,45.98,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,574.72,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,,,,,,,350.56,,,fee schedule,,,568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,426.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",369.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",431.04,,,percent of total billed charges,,,574.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,574.72,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,32.73,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
CARPAL TUNNEL TX INJ RT,2800000207,CDM,761,RC,20526,CPT,5441,APC,,,,outpatient,facility,,,574.72,574.72,332.88,500.18,,,,,,,,355.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,344.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.4,,,fee schedule,,,,,,,,,344.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,344.95,,,fee schedule,,,,,,,,,,,,,,,362.13,,,fee schedule,,,362.2,,,fee schedule,,,,,,,,,344.95,,,fee schedule,,,344.95,,,fee schedule,,,362.2,,,fee schedule,,,,,,,,,,,,,,,500.18,,,fee schedule,,,,,,,,,,,,,,,355.26,,,fee schedule,,,,,,,,,,,,,,,332.88,,,fee schedule,,,369.1,,,fee schedule,,,368.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.95,,,fee schedule,,,344.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,364.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,431.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,344.95,,,fee schedule,,,344.95,,,fee schedule,,,,,,,,,,,,,,,344.95,,,fee schedule,,,,,,,,,,,,,,,344.95,,,fee schedule,,,355.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,390.25,,,fee schedule,,,344.95,,,fee schedule,,,366.34,,,fee schedule,,,344.95,,,fee schedule,,,344.95,,,fee schedule,,,350.56,,,fee schedule,,,,,,,,,350.56,,,fee schedule,,,,,,,,
CARPAL TUNNEL TX INJ RT,2800000207,CDM,761,RC,20526,CPT,49,EAPG,,,,outpatient,facility,,,574.72,574.72,252.97,370.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.85,,,fee schedule,,,252.97,,,fee schedule,,,329.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,252.97,,,fee schedule,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INJ SGL TENDN SHTH LIGMENT RT,2800000208,CDM,761,RC,20550,CPT,,,,,,inpatient,facility,,,574.72,574.72,45.98,574.72,,,,,,,,,,,,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,517.25,,,percent of total billed charges,,,,,,,,,574.72,,,percent of total billed charges,,,318.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,524.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,574.72,,,percent of total billed charges,,,299.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.98,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.57,,,percent of total billed charges,,
INJ SGL TENDN SHTH LIGMENT RT,2800000208,CDM,761,RC,20550,CPT,,,,,,outpatient,facility,,,574.72,574.72,24.64,691.42,,335.64,,,percent of total billed charges,,,,,,,,,574.72,,,percent of total billed charges,,,403.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,449.42,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,449.42,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,517.25,,,percent of total billed charges,,,,,,,,,574.72,,,percent of total billed charges,,,389.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,441.38,,,percent of total billed charges,,,,,,,,,,,,,,,653.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",691.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,299.66,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,436.79,,,percent of total billed charges,,,217.7,,,percent of total billed charges,,,297.65,,,percent of total billed charges,,,,,,,,,,,,,,,114.94,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,497.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",221.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,45.98,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,574.72,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,,,,,,,350.56,,,fee schedule,,,568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,426.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",369.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",431.04,,,percent of total billed charges,,,574.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,574.72,,,percent of total billed charges,,,574.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,24.64,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
INJ SGL TENDN SHTH LIGMENT RT,2800000208,CDM,761,RC,20550,CPT,5441,APC,,,,outpatient,facility,,,574.72,574.72,332.88,500.18,,,,,,,,355.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,344.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.4,,,fee schedule,,,,,,,,,344.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,344.95,,,fee schedule,,,,,,,,,,,,,,,362.13,,,fee schedule,,,362.2,,,fee schedule,,,,,,,,,344.95,,,fee schedule,,,344.95,,,fee schedule,,,362.2,,,fee schedule,,,,,,,,,,,,,,,500.18,,,fee schedule,,,,,,,,,,,,,,,355.26,,,fee schedule,,,,,,,,,,,,,,,332.88,,,fee schedule,,,369.1,,,fee schedule,,,368.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.95,,,fee schedule,,,344.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,364.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,431.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,344.95,,,fee schedule,,,344.95,,,fee schedule,,,,,,,,,,,,,,,344.95,,,fee schedule,,,,,,,,,,,,,,,344.95,,,fee schedule,,,355.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,390.25,,,fee schedule,,,344.95,,,fee schedule,,,366.34,,,fee schedule,,,344.95,,,fee schedule,,,344.95,,,fee schedule,,,350.56,,,fee schedule,,,,,,,,,350.56,,,fee schedule,,,,,,,,
INJ SGL TENDN SHTH LIGMENT RT,2800000208,CDM,761,RC,20550,CPT,49,EAPG,,,,outpatient,facility,,,574.72,574.72,252.97,370.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.85,,,fee schedule,,,252.97,,,fee schedule,,,329.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,252.97,,,fee schedule,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DRN/INJ SM JNT/BRSA WO US RT,2800000209,CDM,761,RC,,,,,,,,inpatient,facility,,,522.8,522.8,41.82,522.8,,,,,,,,,,,,,,522.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470.52,,,percent of total billed charges,,,,,,,,,522.8,,,percent of total billed charges,,,289.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,477,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.8,,,percent of total billed charges,,,,,,,,,,,,,,,522.8,,,percent of total billed charges,,,272.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.82,,,percent of total billed charges,,,522.8,,,percent of total billed charges,,,522.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,522.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,367.11,,,percent of total billed charges,,
DRN/INJ SM JNT/BRSA WO US RT,2800000209,CDM,761,RC,,,,,,,,outpatient,facility,,,522.8,522.8,41.82,618.77,,305.32,,,percent of total billed charges,,,101.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,522.8,,,percent of total billed charges,,,460.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,460.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,460.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,522.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,191.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,470.52,,,percent of total billed charges,,,,,,,,,522.8,,,percent of total billed charges,,,354.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.51,,,percent of total billed charges,,,,,,,,,,,,,,,282.31,,,percent of total billed charges,,,282.31,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,522.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,272.59,,,percent of total billed charges,,,522.8,,,percent of total billed charges,,,522.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.33,,,percent of total billed charges,,,198.04,,,percent of total billed charges,,,270.76,,,percent of total billed charges,,,,,,,,,,,,,,,104.56,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,193.44,,,percent of total billed charges,,,193.44,,,percent of total billed charges,,,522.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,522.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,41.82,,,percent of total billed charges,,,522.8,,,percent of total billed charges,,,522.8,,,percent of total billed charges,,,,,,,,,,,,,,,522.8,,,percent of total billed charges,,,522.8,,,percent of total billed charges,,,,,,,,,522.8,,,fee schedule,,,486.31,,,percent of total billed charges,,,,,,,,,,,,,,,486.31,,,percent of total billed charges,,,486.31,,,percent of total billed charges,,,486.31,,,percent of total billed charges,,,392.1,,,percent of total billed charges,,,522.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,522.8,,,percent of total billed charges,,,522.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,367.11,,,percent of total billed charges,,
DRN/INJ SM JNT/BRSA WO US RT,2800000209,CDM,761,RC,999,EAPG,,,,,,outpatient,facility,,,522.8,522.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DRN/INJ MAJ JNT/BRSA WO US RT,2800000211,CDM,761,RC,20610,CPT,,,,,,inpatient,facility,,,642.69,642.69,51.42,642.69,,,,,,,,,,,,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.42,,,percent of total billed charges,,,,,,,,,642.69,,,percent of total billed charges,,,355.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,586.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,642.69,,,percent of total billed charges,,,335.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.42,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,451.3,,,percent of total billed charges,,
DRN/INJ MAJ JNT/BRSA WO US RT,2800000211,CDM,761,RC,20610,CPT,,,,,,outpatient,facility,,,642.69,642.69,37.14,691.42,,375.33,,,percent of total billed charges,,,,,,,,,642.69,,,percent of total billed charges,,,403.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,449.42,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,449.42,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,578.42,,,percent of total billed charges,,,,,,,,,642.69,,,percent of total billed charges,,,435.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,fee schedule,,,,,,,,,493.59,,,percent of total billed charges,,,,,,,,,,,,,,,653.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",691.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,335.1,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,488.44,,,percent of total billed charges,,,243.45,,,percent of total billed charges,,,332.85,,,percent of total billed charges,,,,,,,,,,,,,,,128.54,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,497.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",221.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,51.42,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,642.69,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,,,,,,,350.56,,,fee schedule,,,568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,426.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",568.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",369.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",482.02,,,percent of total billed charges,,,642.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,642.69,,,percent of total billed charges,,,642.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,321.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,37.14,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
DRN/INJ MAJ JNT/BRSA WO US RT,2800000211,CDM,761,RC,20610,CPT,5441,APC,,,,outpatient,facility,,,642.69,642.69,332.88,500.18,,,,,,,,355.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,344.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.4,,,fee schedule,,,,,,,,,344.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,344.95,,,fee schedule,,,,,,,,,,,,,,,362.13,,,fee schedule,,,362.2,,,fee schedule,,,,,,,,,344.95,,,fee schedule,,,,,,,,,362.2,,,fee schedule,,,,,,,,,,,,,,,500.18,,,fee schedule,,,,,,,,,,,,,,,355.26,,,fee schedule,,,,,,,,,,,,,,,332.88,,,fee schedule,,,369.1,,,fee schedule,,,368.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.95,,,fee schedule,,,344.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,364.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,431.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,344.95,,,fee schedule,,,344.95,,,fee schedule,,,,,,,,,,,,,,,344.95,,,fee schedule,,,,,,,,,,,,,,,344.95,,,fee schedule,,,355.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,390.25,,,fee schedule,,,344.95,,,fee schedule,,,366.34,,,fee schedule,,,344.95,,,fee schedule,,,344.95,,,fee schedule,,,350.56,,,fee schedule,,,,,,,,,350.56,,,fee schedule,,,,,,,,
DRN/INJ MAJ JNT/BRSA WO US RT,2800000211,CDM,761,RC,20610,CPT,49,EAPG,,,,outpatient,facility,,,642.69,642.69,252.97,370.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.85,,,fee schedule,,,252.97,,,fee schedule,,,329.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,252.97,,,fee schedule,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,252.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INF BURSA I&D UA/ELBOW RT,2800000212,CDM,761,RC,23931,CPT,,,,,,inpatient,facility,,,4367.96,4367.96,349.44,4367.96,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3931.16,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2418.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3985.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,2277.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.44,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3067.18,,,percent of total billed charges,,
INF BURSA I&D UA/ELBOW RT,2800000212,CDM,761,RC,23931,CPT,,,,,,outpatient,facility,,,4367.96,4367.96,319.69,4428.39,,2550.89,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2244.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,3931.16,,,percent of total billed charges,,,,,,,,,4367.96,,,percent of total billed charges,,,2957.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3354.59,,,percent of total billed charges,,,,,,,,,,,,,,,4129.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",4370.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2277.45,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1250,,,case rate,,,1654.58,,,percent of total billed charges,,,2262.17,,,percent of total billed charges,,,,,,,,,,,,,,,873.59,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,3873.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",1726.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,349.44,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,1924.13,,,fee schedule,,,4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,3321.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",4428.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",2878.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",3275.97,,,percent of total billed charges,,,4367.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,4367.96,,,percent of total billed charges,,,4367.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2183.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,818.67,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
INF BURSA I&D UA/ELBOW RT,2800000212,CDM,761,RC,23931,CPT,5072,APC,,,,outpatient,facility,,,4367.96,4367.96,1827.07,2745.34,,,,,,,,1950.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1912.27,,,fee schedule,,,,,,,,,1893.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1987.63,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,,,,,,,2745.34,,,fee schedule,,,,,,,,,,,,,,,1949.91,,,fee schedule,,,,,,,,,,,,,,,1827.07,,,fee schedule,,,2025.87,,,fee schedule,,,2020.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1950.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.22,,,fee schedule,,,1893.34,,,fee schedule,,,2010.72,,,fee schedule,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1924.13,,,fee schedule,,,,,,,,,1924.13,,,fee schedule,,,,,,,,
INF BURSA I&D UA/ELBOW RT,2800000212,CDM,761,RC,23931,CPT,999,EAPG,,,,outpatient,facility,,,4367.96,4367.96,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REM FB UP ARM OR ELBOW; SQ RT,2800000213,CDM,761,RC,24200,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
REM FB UP ARM OR ELBOW; SQ RT,2800000213,CDM,761,RC,24200,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,112.89,2497.86,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,2244.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,2497.86,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,1403.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",1485.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1384.42,,,percent of total billed charges,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,1924.13,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,112.89,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
REM FB UP ARM OR ELBOW; SQ RT,2800000213,CDM,761,RC,24200,CPT,5072,APC,,,,outpatient,facility,,,1821.6,1821.6,1827.07,2745.34,,,,,,,,1950.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1912.27,,,fee schedule,,,,,,,,,1893.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1987.63,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1988.01,,,fee schedule,,,,,,,,,,,,,,,2745.34,,,fee schedule,,,,,,,,,,,,,,,1949.91,,,fee schedule,,,,,,,,,,,,,,,1827.07,,,fee schedule,,,2025.87,,,fee schedule,,,2020.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2366.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,,,,,,,,,,,,,1893.34,,,fee schedule,,,1950.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.22,,,fee schedule,,,1893.34,,,fee schedule,,,2010.72,,,fee schedule,,,1893.34,,,fee schedule,,,1893.34,,,fee schedule,,,1924.13,,,fee schedule,,,,,,,,,1924.13,,,fee schedule,,,,,,,,
REM FB UP ARM OR ELBOW; SQ RT,2800000213,CDM,761,RC,24200,CPT,51,EAPG,,,,outpatient,facility,,,1821.6,1821.6,1857.72,2723.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2723.42,,,fee schedule,,,1857.72,,,fee schedule,,,2421.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1857.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1857.72,,,fee schedule,,,1857.72,,,fee schedule,,,1857.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1857.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1857.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REM FB FOOT; SQ RT,2800000214,CDM,761,RC,28190,CPT,,,,,,inpatient,facility,,,1821.6,1821.6,145.73,1821.6,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1008.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,949.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.13,,,percent of total billed charges,,
REM FB FOOT; SQ RT,2800000214,CDM,761,RC,28190,CPT,,,,,,outpatient,facility,,,1821.6,1821.6,136.06,2910.72,,1063.81,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,945.4,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1052.07,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1639.44,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1233.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.99,,,percent of total billed charges,,,,,,,,,,,,,,,2750.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2910.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,949.78,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1384.42,,,percent of total billed charges,,,690.02,,,percent of total billed charges,,,943.41,,,percent of total billed charges,,,,,,,,,,,,,,,364.32,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,145.73,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,835.56,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1366.2,,,percent of total billed charges,,,1821.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1821.6,,,percent of total billed charges,,,1821.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,136.06,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
REM FB FOOT; SQ RT,2800000214,CDM,761,RC,28190,CPT,5071,APC,,,,outpatient,facility,,,1821.6,1821.6,793.41,1192.18,,,,,,,,846.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.41,,,fee schedule,,,,,,,,,822.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,863.14,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,863.3,,,fee schedule,,,,,,,,,,,,,,,1192.18,,,fee schedule,,,,,,,,,,,,,,,846.76,,,fee schedule,,,,,,,,,,,,,,,793.41,,,fee schedule,,,879.74,,,fee schedule,,,877.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,868.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1027.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,,,,,,,,,,,,,822.19,,,fee schedule,,,846.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.04,,,fee schedule,,,822.19,,,fee schedule,,,873.16,,,fee schedule,,,822.19,,,fee schedule,,,822.19,,,fee schedule,,,835.56,,,fee schedule,,,,,,,,,835.56,,,fee schedule,,,,,,,,
REM FB FOOT; SQ RT,2800000214,CDM,761,RC,28190,CPT,9,EAPG,,,,outpatient,facility,,,1821.6,1821.6,746.17,1093.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.89,,,fee schedule,,,746.17,,,fee schedule,,,972.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,746.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
APPLY SHORT ARM CAST RT,2800000215,CDM,761,RC,29075,CPT,,,,,,inpatient,facility,,,714.22,714.22,57.14,714.22,,,,,,,,,,,,,,714.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,642.8,,,percent of total billed charges,,,,,,,,,714.22,,,percent of total billed charges,,,395.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,714.22,,,percent of total billed charges,,,,,,,,,,,,,,,714.22,,,percent of total billed charges,,,372.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.14,,,percent of total billed charges,,,714.22,,,percent of total billed charges,,,714.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,714.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,501.53,,,percent of total billed charges,,
APPLY SHORT ARM CAST RT,2800000215,CDM,761,RC,29075,CPT,,,,,,outpatient,facility,,,714.22,714.22,45.59,714.22,,417.1,,,percent of total billed charges,,,,,,,,,714.22,,,percent of total billed charges,,,384.43,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,427.81,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,427.81,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,714.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,642.8,,,percent of total billed charges,,,,,,,,,714.22,,,percent of total billed charges,,,483.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,548.52,,,percent of total billed charges,,,,,,,,,,,,,,,607.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",642.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,714.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,372.39,,,percent of total billed charges,,,714.22,,,percent of total billed charges,,,714.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,542.81,,,percent of total billed charges,,,270.55,,,percent of total billed charges,,,369.89,,,percent of total billed charges,,,,,,,,,,,,,,,142.84,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,657.53,,,fee schedule,,,293.16,,,fee schedule,,,,,,,,,,,,,,,57.14,,,percent of total billed charges,,,714.22,,,percent of total billed charges,,,714.22,,,percent of total billed charges,,,,,,,,,,,,,,,714.22,,,percent of total billed charges,,,714.22,,,percent of total billed charges,,,,,,,,,315.39,,,fee schedule,,,646.27,,,fee schedule,,,,,,,,,,,,,,,568.32,,,fee schedule,,,714.22,,,fee schedule,,,420.08,,,fee schedule,,,535.66,,,percent of total billed charges,,,714.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,714.22,,,percent of total billed charges,,,714.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.11,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,45.59,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
APPLY SHORT ARM CAST RT,2800000215,CDM,761,RC,29075,CPT,5102,APC,,,,outpatient,facility,,,714.22,714.22,299.48,449.99,,,,,,,,319.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,310.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.44,,,fee schedule,,,,,,,,,310.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,310.34,,,fee schedule,,,,,,,,,,,,,,,325.8,,,fee schedule,,,325.86,,,fee schedule,,,,,,,,,310.34,,,fee schedule,,,310.34,,,fee schedule,,,325.86,,,fee schedule,,,,,,,,,,,,,,,449.99,,,fee schedule,,,,,,,,,,,,,,,319.61,,,fee schedule,,,,,,,,,,,,,,,299.48,,,fee schedule,,,332.06,,,fee schedule,,,331.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,310.34,,,fee schedule,,,310.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,328.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,387.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,387.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,310.34,,,fee schedule,,,310.34,,,fee schedule,,,,,,,,,,,,,,,310.34,,,fee schedule,,,,,,,,,,,,,,,310.34,,,fee schedule,,,319.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,353.86,,,fee schedule,,,310.34,,,fee schedule,,,329.58,,,fee schedule,,,310.34,,,fee schedule,,,310.34,,,fee schedule,,,315.39,,,fee schedule,,,,,,,,,315.39,,,fee schedule,,,,,,,,
APPLY SHORT ARM CAST RT,2800000215,CDM,761,RC,29075,CPT,39,EAPG,,,,outpatient,facility,,,714.22,714.22,244.72,358.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.76,,,fee schedule,,,244.72,,,fee schedule,,,318.94,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.72,,,fee schedule,,,244.72,,,fee schedule,,,244.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,244.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BONE MARROW BIOPSY RT,2800000219,CDM,761,RC,,,,,,,,inpatient,facility,,,1544.04,1544.04,123.52,1544.04,,,,,,,,,,,,,,1544.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1389.64,,,percent of total billed charges,,,,,,,,,1544.04,,,percent of total billed charges,,,854.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1544.04,,,percent of total billed charges,,,,,,,,,,,,,,,1544.04,,,percent of total billed charges,,,805.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.52,,,percent of total billed charges,,,1544.04,,,percent of total billed charges,,,1544.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1544.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1084.22,,,percent of total billed charges,,
BONE MARROW BIOPSY RT,2800000219,CDM,761,RC,,,,,,,,outpatient,facility,,,1544.04,1544.04,123.52,1544.04,,901.72,,,percent of total billed charges,,,301.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,1544.04,,,percent of total billed charges,,,1359.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,1359.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,1359.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 88.04%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1544.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,565.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1389.64,,,percent of total billed charges,,,,,,,,,1544.04,,,percent of total billed charges,,,1045.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1185.82,,,percent of total billed charges,,,,,,,,,,,,,,,833.78,,,percent of total billed charges,,,833.78,,,percent of total billed charges,,,,,,,,,618.77,,,per diem,,,1544.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,805.06,,,percent of total billed charges,,,1544.04,,,percent of total billed charges,,,1544.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1173.47,,,percent of total billed charges,,,584.88,,,percent of total billed charges,,,799.66,,,percent of total billed charges,,,,,,,,,,,,,,,308.81,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,571.29,,,percent of total billed charges,,,571.29,,,percent of total billed charges,,,1544.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1544.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,123.52,,,percent of total billed charges,,,1544.04,,,percent of total billed charges,,,1544.04,,,percent of total billed charges,,,,,,,,,,,,,,,1544.04,,,percent of total billed charges,,,1544.04,,,percent of total billed charges,,,,,,,,,1544.04,,,fee schedule,,,1436.27,,,percent of total billed charges,,,,,,,,,,,,,,,1436.27,,,percent of total billed charges,,,1436.27,,,percent of total billed charges,,,1436.27,,,percent of total billed charges,,,1158.03,,,percent of total billed charges,,,1544.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1544.04,,,percent of total billed charges,,,1544.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,772.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,1084.22,,,percent of total billed charges,,
BONE MARROW BIOPSY RT,2800000219,CDM,761,RC,999,EAPG,,,,,,outpatient,facility,,,1544.04,1544.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NRV BLCK ILIOING/ILIOGASTRC RT,2800000221,CDM,761,RC,64425,CPT,,,,,,inpatient,facility,,,1164.14,1164.14,93.13,1164.14,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1047.73,,,percent of total billed charges,,,,,,,,,1164.14,,,percent of total billed charges,,,644.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1062.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,606.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.13,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,817.46,,,percent of total billed charges,,
NRV BLCK ILIOING/ILIOGASTRC RT,2800000221,CDM,761,RC,64425,CPT,,,,,,outpatient,facility,,,1164.14,1164.14,54.06,1808.18,,679.86,,,percent of total billed charges,,,,,,,,,1164.14,,,percent of total billed charges,,,977.17,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1087.41,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1087.41,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1047.73,,,percent of total billed charges,,,,,,,,,1164.14,,,percent of total billed charges,,,788.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.06,,,percent of total billed charges,,,,,,,,,,,,,,,1708.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",1808.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,606.98,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,884.75,,,percent of total billed charges,,,440.98,,,percent of total billed charges,,,602.91,,,percent of total billed charges,,,,,,,,,,,,,,,232.83,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1036.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",462.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,93.13,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,1164.14,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,,,,,,,822.41,,,fee schedule,,,1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,889.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1185.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",770.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",436.77,,,fee schedule,,,1164.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1164.14,,,percent of total billed charges,,,1164.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,582.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,54.06,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
NRV BLCK ILIOING/ILIOGASTRC RT,2800000221,CDM,761,RC,64425,CPT,5442,APC,,,,outpatient,facility,,,1164.14,1164.14,780.93,1173.41,,,,,,,,833.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,809.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,817.34,,,fee schedule,,,,,,,,,809.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,809.25,,,fee schedule,,,,,,,,,,,,,,,849.55,,,fee schedule,,,849.71,,,fee schedule,,,,,,,,,809.25,,,fee schedule,,,809.25,,,fee schedule,,,849.71,,,fee schedule,,,,,,,,,,,,,,,1173.41,,,fee schedule,,,,,,,,,,,,,,,833.43,,,fee schedule,,,,,,,,,,,,,,,780.93,,,fee schedule,,,865.9,,,fee schedule,,,863.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,809.25,,,fee schedule,,,809.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,855.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1011.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1011.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,809.25,,,fee schedule,,,809.25,,,fee schedule,,,,,,,,,,,,,,,809.25,,,fee schedule,,,,,,,,,,,,,,,809.25,,,fee schedule,,,833.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,911.18,,,fee schedule,,,809.25,,,fee schedule,,,859.42,,,fee schedule,,,809.25,,,fee schedule,,,809.25,,,fee schedule,,,822.41,,,fee schedule,,,,,,,,,822.41,,,fee schedule,,,,,,,,
NRV BLCK ILIOING/ILIOGASTRC RT,2800000221,CDM,761,RC,64425,CPT,214,EAPG,,,,outpatient,facility,,,1164.14,1164.14,409.47,600.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.28,,,fee schedule,,,409.47,,,fee schedule,,,533.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,409.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,409.47,,,fee schedule,,,409.47,,,fee schedule,,,409.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,409.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,409.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXC EYELID LES WO CLSE/SIM RT,2800000222,CDM,761,RC,67840,CPT,,,,,,inpatient,facility,,,1829.57,1829.57,146.37,1829.57,,,,,,,,,,,,,,1829.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1646.61,,,percent of total billed charges,,,,,,,,,1829.57,,,percent of total billed charges,,,1012.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1669.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1829.57,,,percent of total billed charges,,,,,,,,,,,,,,,1829.57,,,percent of total billed charges,,,953.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,365.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.37,,,percent of total billed charges,,,1829.57,,,percent of total billed charges,,,1829.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1829.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1284.72,,,percent of total billed charges,,
EXC EYELID LES WO CLSE/SIM RT,2800000222,CDM,761,RC,67840,CPT,,,,,,outpatient,facility,,,1829.57,1829.57,146.37,2152.83,,1068.47,,,percent of total billed charges,,,,,,,,,1829.57,,,percent of total billed charges,,,1317.38,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,1466.01,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,1466.01,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1829.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1646.61,,,percent of total billed charges,,,,,,,,,1829.57,,,percent of total billed charges,,,1238.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1405.11,,,percent of total billed charges,,,,,,,,,,,,,,,2034.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",2152.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1829.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,953.94,,,percent of total billed charges,,,1829.57,,,percent of total billed charges,,,1829.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1390.47,,,percent of total billed charges,,,693.04,,,percent of total billed charges,,,947.53,,,percent of total billed charges,,,,,,,,,,,,,,,365.91,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,146.37,,,percent of total billed charges,,,1829.57,,,percent of total billed charges,,,1829.57,,,percent of total billed charges,,,,,,,,,,,,,,,1829.57,,,percent of total billed charges,,,1829.57,,,percent of total billed charges,,,,,,,,,1150.2,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1372.18,,,percent of total billed charges,,,1829.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1829.57,,,percent of total billed charges,,,1829.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,914.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,172.47,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
EXC EYELID LES WO CLSE/SIM RT,2800000222,CDM,761,RC,67840,CPT,5502,APC,,,,outpatient,facility,,,1829.57,1829.57,1092.19,1641.11,,,,,,,,1165.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1131.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1143.12,,,fee schedule,,,,,,,,,1131.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,1131.8,,,fee schedule,,,,,,,,,,,,,,,1188.16,,,fee schedule,,,1188.39,,,fee schedule,,,,,,,,,1131.8,,,fee schedule,,,1131.8,,,fee schedule,,,1188.39,,,fee schedule,,,,,,,,,,,,,,,1641.11,,,fee schedule,,,,,,,,,,,,,,,1165.62,,,fee schedule,,,,,,,,,,,,,,,1092.19,,,fee schedule,,,1211.03,,,fee schedule,,,1207.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1131.8,,,fee schedule,,,1131.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1196.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1414.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1414.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1131.8,,,fee schedule,,,1131.8,,,fee schedule,,,,,,,,,,,,,,,1131.8,,,fee schedule,,,,,,,,,,,,,,,1131.8,,,fee schedule,,,1165.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1333.99,,,fee schedule,,,1131.8,,,fee schedule,,,1201.96,,,fee schedule,,,1131.8,,,fee schedule,,,1131.8,,,fee schedule,,,1150.2,,,fee schedule,,,,,,,,,1150.2,,,fee schedule,,,,,,,,
EXC EYELID LES WO CLSE/SIM RT,2800000222,CDM,761,RC,67840,CPT,258,EAPG,,,,outpatient,facility,,,1829.57,1829.57,1480.88,2170.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2170.97,,,fee schedule,,,1480.88,,,fee schedule,,,1930.03,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1480.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1480.88,,,fee schedule,,,1480.88,,,fee schedule,,,1480.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1480.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1480.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TYMPANOSTOMY LOCAL RT,2800000223,CDM,761,RC,69433,CPT,,,,,,inpatient,facility,,,1807.08,1807.08,144.57,1807.08,,,,,,,,,,,,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.37,,,percent of total billed charges,,,,,,,,,1807.08,,,percent of total billed charges,,,1000.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1648.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,1807.08,,,percent of total billed charges,,,942.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,361.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.57,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1268.93,,,percent of total billed charges,,
TYMPANOSTOMY LOCAL RT,2800000223,CDM,761,RC,69433,CPT,,,,,,outpatient,facility,,,1807.08,1807.08,117.68,1857.83,,1055.33,,,percent of total billed charges,,,,,,,,,1807.08,,,percent of total billed charges,,,794.92,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,884.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,884.61,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,,,,,,,,,,,,,,,,,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.03,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $351.03.   If ( Current Amount = 0 )   Then:  $351.03 Flat ,,,,,,,319.69,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $319.69.   If ( Current Amount = 0 )   Then:  $319.69 Flat ,1626.37,,,percent of total billed charges,,,,,,,,,1807.08,,,percent of total billed charges,,,1223.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1387.84,,,percent of total billed charges,,,,,,,,,,,,,,,913.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (292.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",966.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITH REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 2   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple Procedure Reduction are payable at the rate indicated for the procedure from the highest payment group.   If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [HP GENERAL OP WITHOUT REDUCTIONS]: (309.00% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [HPHC OP MOD]    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedu",,,,,,,618.77,,,per diem,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,942.21,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1373.38,,,percent of total billed charges,,,684.52,,,percent of total billed charges,,,935.89,,,percent of total billed charges,,,,,,,,,,,,,,,361.42,,,percent of total billed charges,,,335.76,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $335.76.   If ( Current Amount = 0 )   Then:  $335.76 Flat ,,,,,,,1624.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (220.70% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Mul",724.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [NETWORK QHP ASC NO REDUCTION BILATERAL]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [NETWORK QHP ASC ELIGIBLE FOR REDUCTION]: (98.40% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [NETWORK QHP MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multip",,,,,,,,,,,,,144.57,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,1807.08,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,,,,,,,604.76,,,fee schedule,,,1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS HMO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS HMO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",,,,,,,,,,,,,1393.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SPIRIT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1857.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS PPO MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS PPO MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     Multiple P",1207.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [TUFTS SELECT MHMC ASC NO REDUCTION BILATERAL]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]     Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with highest reimbursement in the fee schedules listed below):    [TUFTS SELECT MHMC ASC ELIGIBLE FOR REDUCTION MHMC]: (100% of base rate in table)     Mod 50 Version 1   Modifier Tables (Apply modifier value from table when applicable):    [MOD 50]    [TUFTS MODS]     Apply the following multipliers to the calculated amount from above for     1st procedure payable at 100%.    2nd procedure and all subsequent procedures payable at 50%.     M",1355.31,,,percent of total billed charges,,,1807.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,1807.08,,,percent of total billed charges,,,1807.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,117.68,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If ",other,,"Procedure Lookup:  Procedure Code Tables:   [[MA WC ASC]] 100.00% of Table  Multipliers: 100.00%, 50.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: ({Current Amount} = 0.00) Then:  FormulaCPE:   (({Charges In Service Type} - {Charges In Pass-Through Section}) * 70.22%)  End FormulaCPE End If "
TYMPANOSTOMY LOCAL RT,2800000223,CDM,761,RC,69433,CPT,5162,APC,,,,outpatient,facility,,,1807.08,1807.08,574.25,862.87,,,,,,,,612.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 19.50%    Percent when code not payable by Medicare: 19.50%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  19.50 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,595.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,601.03,,,fee schedule,,,,,,,,,595.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 220073     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 100% of fee schedule amount.   Override FS - Air with 100% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount.   Apply sequestration reduction If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ",,,,,,,,,,,,,595.08,,,fee schedule,,,,,,,,,,,,,,,624.72,,,fee schedule,,,624.83,,,fee schedule,,,,,,,,,595.08,,,fee schedule,,,595.08,,,fee schedule,,,624.83,,,fee schedule,,,,,,,,,,,,,,,862.87,,,fee schedule,,,,,,,,,,,,,,,612.86,,,fee schedule,,,,,,,,,,,,,,,574.25,,,fee schedule,,,636.74,,,fee schedule,,,635,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,595.08,,,fee schedule,,,595.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,628.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,743.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220073    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220073  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,595.08,,,fee schedule,,,595.08,,,fee schedule,,,,,,,,,,,,,,,595.08,,,fee schedule,,,,,,,,,,,,,,,595.08,,,fee schedule,,,612.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,724.96,,,fee schedule,,,595.08,,,fee schedule,,,631.97,,,fee schedule,,,595.08,,,fee schedule,,,595.08,,,fee schedule,,,604.76,,,fee schedule,,,,,,,,,604.76,,,fee schedule,,,,,,,,
TYMPANOSTOMY LOCAL RT,2800000223,CDM,761,RC,69433,CPT,249,EAPG,,,,outpatient,facility,,,1807.08,1807.08,194.73,285.47,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,285.47,,,fee schedule,,,194.73,,,fee schedule,,,253.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.73,,,fee schedule,,,194.73,,,fee schedule,,,194.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,194.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REMOVL OF BREAST LESION 1+ LT,2800000224,CDM,761,RC,19120,CPT,,,,,,inpatient,facility,,,6409.39,6409.39,512.75,6409.39,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5768.45,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,3548.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5847.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,3341.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1281.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.75,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6409.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4500.67,,,percent of total billed charges,,
REMOVL OF BREAST LESION 1+ LT,2800000224,CDM,761,RC,19120,CPT,,,,,,outpatient,facility,,,6409.39,6409.39,319.69,6930.49,,3743.08,,,percent of total billed charges,,,,,,,,,6409.39,,,percent of total billed charges,,,4595.33,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not p,5113.79,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,other,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amount.    4th procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are no,,,,,,,5113.79,,Interim Value: ASC Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure and all subsequent procedures payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers. Interim Value: Bundled Charges   Formula:= ( Charges In Service Type - ASC Charges ) Interim Value: Primary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: Secondary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Tertiary Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 100.00% of charge amount.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable.    Multiple Procedure Reduction are payable at the rate indicated for the procedure     from the highest payment group.  Interim Value: Fourth Proc Charges   Procedure Lookup Tables:     [BCBS ASC ALL]       1st procedure payable at 0.00% of charge amount.    2nd procedure payable at 0.00% of charge amount.    3rd procedure payable at 0.00% of charge amo